Methods and assays relating to the treatment of infection

ABSTRACT

The technology described herein is directed to the diagnosis, prognosis, and treatment of infection, e.g. after burn injury.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is divisional under 35 U.S.C. § 121 of co-pending U.S. application Ser. No. 15/027,067 filed Apr. 4, 2016, which is a 35 U.S.C. § 371 National Phase Entry Application of International Application No. PCT/US2014/065444 filed Nov. 13, 2014, which designates the U.S. and claims benefit under 35 U.S.C. § 119(e) of U.S. Provisional Application No. 61/903,548 filed Nov. 13, 2013, the contents of which are incorporated herein by reference in their entireties.

GOVERNMENT SUPPORT

This invention was made with Government support under grant number W81XWH-12-2-0007 awarded by the Department of Defense. The Government has certain rights in the invention.

TECHNICAL FIELD

The technology described herein relates to the diagnosis, prognosis, and treatment of infection, e.g. following burn injury or inhalation injury.

BACKGROUND

Severe trauma, e.g., burn injury, can cause immunosuppression, predisposing patients to infections. Despite all medical improvements, infections remain a major cause of critical injury-related morbidity and mortality, and recurrent sepsis predisposes patients to multiple organ failure, lengthens hospital stays, and increases costs. Moreover, the rapid emergence of multi-(MDR) or pan-drug resistant (PDR) pathogens that cause highly problematic acute, persistent or relapsing infections pose a dire threat to healthcare, especially among trauma and surgical patients. Due to the paucity of novel anti-infectives in development, further improvement in patient care and treatment efficacy may rely heavily on optimizing existing strategies and promoting patients-tailored therapies. Presently available tests are directed to diagnosing existing cases of sepsis, rather than identifying patients who will develop such conditions.

SUMMARY

A successful personalized approach requires rigorous triaging: early and accurate identification of patients more susceptible to infections can help tailor the anti-infective treatments and especially to elaborate long-term treatment plan. As described herein, the inventors have identified a gene expression signature that accurate identifies the patients who will succumb to infection. The methods and assays described herein are demonstrated to be significantly more accurate than traditional clinical characteristic triaging.

In one aspect, described herein is an assay comprising: measuring the level of a gene expression product of at least one gene of Tables 4 and 5 a test sample obtained from a subject; wherein a decrease in the level of a gene expression product of a gene of Table 4 relative to a reference level indicates the subject has a higher risk of having or developing an infection and an increase in the level of a gene expression product of a gene of Table 5 relative to a reference level indicates the subject has a higher risk of having or developing an infection.

In one aspect, described herein is an assay comprising: contacting a sample obtained from a subject at risk of developing an infection with a probe to detect the level of a gene expression product of at least one gene of Tables 4 and 5; measuring the presence or intensity of a signal which indicates the presence or level of the gene expression product in the sample; wherein a decrease in the level of a gene expression product of a gene of Table 4 relative to a reference level indicates the subject has a higher risk of having or developing an infection and an increase in the level of a gene expression product of a gene of Table 5 relative to a reference level indicates the subject has a higher risk of having or developing an infection.

In one aspect, described herein is a method of identifying a subject in need of treatment for infection, the method comprising: measuring the level of a gene expression product of at least one gene of Tables 4 and 5 in a test sample obtained from a subject; and identifying the subject as being in need of treatment for infection when the level of a gene expression product of a gene of Table 4 is decreased relative to a reference level and the level of a gene expression product of a gene of Table 5 is increased relative to a reference level.

In one aspect, described herein is a method of determining if a subject is at risk for infection, the method comprising providing a sample obtained from the subject; measuring the level of a gene expression product of at least one gene of Tables 4 and 5 in the sample; comparing the level of the gene expression product in the sample to a reference level of the gene expression product; determining that the subject is at risk for infection when the level of a gene expression product of a gene of Table 4 is decreased relative to a reference level and the level of a gene expression product of a gene of Table 5 is increased relative to a reference level; and determining that the subject is not at risk for infection when the level of a gene expression product of a gene of Table 4 is not decreased relative to a reference level and the level of a gene expression product of a gene of Table 5 is not increased relative to a reference level.

In one aspect, described herein is a method of determining the efficacy of a treatment for infection, the method comprising: (a) measuring the level of a gene expression product of at least one gene of Tables 4 and 5 in a test sample obtained from a subject before administration of the treatment; (b) measuring the level of the gene expression product in a test sample obtained from a subject after administration of the treatment; and wherein the treatment is determined to be efficacious when the level of a gene expression product of a gene of Table 4 measured in step (b) is not decreased relative to the level measured in step (a) and the level of a gene expression product of a gene of Table 5 measured in step (b) is not increased relative to the level measured in step (a). In some embodiments, the treatment for infection is an anti-sepsis treatment.

In one aspect, described herein is a method of treatment for infection comprising; measuring the level of a gene expression product of at least one gene of Tables 4 and 5 in a test sample obtained from a subject; treating the subject with a treatment selected from the group consisting of: antibiotics; extended courses of antibiotics; immunotherapy; and LPS removal; when the level of a gene expression product of a gene of Table 4 is decreased relative to a reference level and the level of a gene expression product of a gene of Table 5 is increased relative to a reference level.

In one aspect, described herein is a method of treatment for infection comprising; administering a treatment selected from the group consisting of: antibiotics; extended courses of antibiotics; immunotherapy; and LPS removal; to a subject determined to have a level of a gene expression product of a gene of Table 4 that is decreased relative to a reference level or a level of a gene expression product of a gene of Table 5 that is increased relative to a reference level.

In some embodiments, the level of a gene expression product is determined by measuring the level of a nucleic acid. In some embodiments, the level of a gene expression product is determined by determined the level of a RNA transcript. In some embodiments, the level of the nucleic acid is determined using a method selected from the group consisting of: RT-PCR; quantitative RT-PCR; Northern blot; microarray based expression analysis; next-generation sequencing; and RNA in situ hybridization. In some embodiments, the level of a gene expression product is determined by measuring the level of a polypeptide. In some embodiments, the level of the polypeptide is determined using a method selected from the group consisting of: Western blot; immunoprecipitation; enzyme-linked immunosorbent assay (ELISA); radioimmunological assay (RIA); sandwich assay; fluorescence in situ hybridization (FISH); immunohistological staining; radioimmunometric assay; immunofluoresence assay; mass spectroscopy; FACS; and immunoelectrophoresis assay. In some embodiments, the polypeptide level is measured using immunochemistry. In some embodiments, the antibody reagent is detectably labeled or generates a detectable signal.

In some embodiments, the expression level is normalized relative to the expression level of one or more reference genes or reference proteins. In some embodiments, the expression level of a gene expression product of at least two genes of Tables 4 and 5 are measured. In some embodiments, the expression level of a gene expression product of at least three genes of Tables 4 and 5 are measured. In some embodiments, the expression level of a gene expression product of at least four genes of Tables 4 and 5 are measured. In some embodiments, the expression level of a gene expression product of at least five genes of Tables 4 and 5 are measured. In some embodiments, the expression level of a gene expression product of at least six genes of Tables 4 and 5 are measured.

In some embodiments, the genes are selected from the group consisting of: THBS1; ARHGEF7; MDFIC; CCND2; OSBPL8; DCAF7; TMEM50B; GOLGA8A and/or GOLGA8B; SMARCA4; WHSC1L1; LOC101928343; and LINC00869. In some embodiments, the expression level of a gene expression product of THBS1; ARHGEF7; MDFIC; CCND2; OSBPL8; DCAF7; TMEM50B; GOLGA8A and/or GOLGA8B; SMARCA4; WHSC1L1; LOC101928343; and LINC00869 is measured.

In some embodiments, the expression level of a gene expression product of CCND2; THBS1; MDFIC; SMARCA4; WHSC1L1; TMEM50B; DCAF7; and OSBPL8 is measured. In some embodiments, the subject is at least 16 years of age or older.

In some embodiments, the expression level of a gene expression product of NFKB2; MAX; PDLIM5; GATAD2B; and ZSCAN30 is measured. In some embodiments, the subject is 15 years of age or younger.

In some embodiments, the sample comprises blood or plasma. In some embodiments, the sample comprises muscle tissue and the one or more genes are selected from the group consisting of: ALDH1A1; ALDH1A2; ALDH3B1; ALDH5A1; ALDH6A1; and ALDH7A1.

In some embodiments, the method or assay further comprises determining the values of total body surface area (TBSA) burns, age, and/or inhalation status; wherein an increase in any of the preceding values indicates an increased risk of the subject having or developing infection. In some embodiments, the method or assay further comprises multiplying each gene expression value measured, and optionally, the total body surface area (TBSA) burns, age, and/or inhalation status values, by a coefficient and adding the resulting products to yield a risk value. In some embodiments, a risk value of greater than the computed reference baseline coefficient value indicates the subject is at risk of having or developing infection and/or is in need of treatment for infection. In some embodiments, the coefficient is about the coefficient provided in Table 7. In some embodiments, a risk value of greater than about −1.1912 indicates the subject is at risk of having or developing infection and/or is in need of treatment for infection.

In some embodiments, the infection comprises a microbe selected from the group consisting of: Gram-negative bacteria; Staphylococcus spp.; Staphylococcus aureus; coagulase-negative Staphylococci; Enterococcus spp.; Candida spp. Escherichia coli; Enterobacter spp.; Klebsiella pneumonia; Acinetobacter spp.; Pseudomonas aeruginosa; Streptococcus pneumonia; Streptococcus viridans; Gram-positive bacteria; Serratia marcescens; Hemophilus influenza; Stenotrophomonas spp.; Proteus; Aspergillus; Neisseria; Clostridium sp.; Bacteroides sp; fungi; cytomegalovirus; and herpes virii. In some embodiments, the subject at risk of infection is a subject at risk of a condition selected from the group consisting of: multiple infection episodes; sepsis; pneumonia; urinary tract infection; blood stream infection; catheter-related infection; and wound infection. In some embodiments, the subject at risk of infection is a subject having or diagnosed as having a condition selected from the group consisting of a burn injury; inhalation injury; immunosuppression; major surgical procedures; intubation or catheters; blunt trauma; penetrating trauma; burn trauma; diabetes; diabetic infection complications; HIV; or is a subject in the intensive care unit and with central lines. In some embodiments, the method or assay further comprises the step of detecting the presence of susceptibility-associated SNPs or pathogen markers in the sample obtained from the subject.

In one aspect, described herein is a kit for performing the methods and/or assays described herein.

In one aspect, described herein is a computer system for determining the risk of a subject having or developing an infection, the system comprising: a measuring module configured to measure the level of a gene expression product of at least one gene of Tables 4 and 5 in a test sample obtained from a subject; a storage module configured to store output data from the determination module; a comparison module adapted to compare the data stored on the storage module with a reference level, and to provide a retrieved content, and a display module for displaying whether the sample comprises a level of the gene expression product which is significantly different relative to the reference expression level and/or displaying the relative level of the gene expression product. In some embodiments, the system further comprises an output module for reporting/displaying the probability of a subject developing infections. In some embodiments, the probablility is calculated from the input from the measuring module and clinical parameters. In some embodiments, the probability is calculated with at least a 95% confidence interval. In some embodiments, the measuring module measures the intensity of a detectable signal from an assay indicating the level of a polypeptide in the test sample. In some embodiments, the assay is an immunoassay. In some embodiments, the measuring module measures the intensity of a detectable signal from a RT-PCR assay indicating the level of a RNA transcript in the test sample. In some embodiments, if the computing module determines that the level of the gene expression product in the test sample obtained from a subject differs by a statistically significant amount from the reference level, the display module displays a signal indicating that the levels in the sample obtained from a subject are different than those of the reference level. In some embodiments, the signal indicates that the subject has an increased likelihood of having or developing an infection. In some embodiments, the signal indicates the subject is in need of treatment for an infection. In some embodiments, the signal indicates the degree to which the level of the gene expression product in the sample obtained from a subject varies from the reference level.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 depicts a diagram of the sample selection process, demonstrating the development of predictive models and discovery of biomarkers.

FIGS. 2A-2B depict graphs demonstrating the type of infections and isolated pathogens. FIG. 2A depicts the types of infection. One case of pseudomembranous colitis represents 0.2%. FIG. 2B depicts the percentage of isolated pathogens among all infection records.

FIGS. 3A-3B demonstrate biomarker selection by LASSO regularized regression. FIG. 3A depicts a representative repetition of 10-fold CV LASSO that chose 14 probe sets at λ_(1se). The first vertical dotted line corresponds to the λ_(min) that minimized binomial deviance during CV. The second dotted line corresponds to λ_(1se), used for the selection of 14 probe sets as shown in FIG. 3B. FIG. 3B depicts LASSO coefficient profile plot of the coefficient paths. At λ_(1se), as shown with the dotted line, 14 probe sets have their coefficients significantly different from zero and thus were chosen as part of the biomarker panel.

FIG. 4 depicts clinical and genomic prediction models. ROC curves of the clinical model, genomic model, and combined model, and their respective AUROC, cross-validated (CV) AUROC, sensitivities, and specificities; 95% CIs are reported in parentheses.

FIG. 5 depicts the alteration of pathways. Top 30 pathways significantly altered in case group with multiple infection episodes (MIE). X-axis is the negative log P value calculated from Fisher's exact test right-tailed. The first number in each grey bar is the number of upregulated genes, the second number in each grey bar is the number of down-regulated genes. The total number of genes in a pathway is indicated in the parenthesis after pathway name. P value is calculated by Fisher's exact test by IPA software.

FIG. 6 is a diagram of an exemplary embodiment of a system for performing an assay for determining the level of a gene expression product in a sample obtained from a subject.

FIG. 7 is a diagram of an exemplary embodiment of an embodiment of a comparison module as described herein. The comparison module depicted in FIG. 7 provides a binary (negative or positive) result. In certain embodiments of the various aspects described herein, the comparison module can provide a probability, e.g. a continuous variable between 0 and 1, rather than merely a binary outcome.

FIG. 8 is a diagram of an exemplary embodiment of an operating system and applications for a computing system as described herein.

FIG. 9A depicts a timeline of the study. FIG. 9B depicts a decision tree used to define independent infection episodes using available clinical and microbiological records. Overriding rules of the decision tree are as included below the table and also described in the methods section.

FIG. 10 depicts graphs of the expression profile of 12 genes in the biomarker panel. A total of 14 probe sets mapped to 12 genes are shown as scatter plot overlaid with notched box plots. P values were calculated using limma package in R software using moderated t-statistics and then adjusted for multiple comparisons using B-H method. Each data point in the scatter plot corresponds to a sample from a patient, and color-coded based on the total infection episodes the patient had from 2 days to 60 days after blood collection.

FIG. 11 depicts an infection episode decision table. Alternative presentation of the decision tree, complementary to FIG. 9B.

DETAILED DESCRIPTION

As described herein, the inventors have identified a gene expression signature that is indicative of hypersusceptibility to infection, e.g. in burn victims. Detection of abnormal levels of expression of one or more of the marker genes described herein permits the identification of patients, with high accuracy, who will succumb to infection, particularly multiple infections. The methods described herein are demonstrated to have significantly greater predictive power than methods utilizing traditional clinical parameters. Accordingly, provided herein are methods and assay relating to the prognosis and treatment of subjects at risk of infection.

As described herein, the inventors have identified certain genes which are upregulated or downregulated to a statistically significant degree in subjects which are at increased risk of, e.g., likely to, experience infection, including multiple infection events. Herein, these genes are referred to as marker genes to indicate their relation to being a marker for this hypersusceptibility. Accordingly, some embodiments of the invention are generally related to assays, methods and systems for assessing the risk of a subject having and/or developing infection(s).

In one aspect, described herein is an assay comprising: measuring the level of a gene expression product of at least one gene of Tables 4 and 5 a test sample obtained from a subject; wherein a decrease in the level of a gene expression product of a gene of Table 4 relative to a reference level indicates the subject has a higher risk of having or developing an infection and an increase in the level of a gene expression product of a gene of Table 5 relative to a reference level indicates the subject has a higher risk of having or developing an infection. In one aspect, described herein is an assay comprising: contacting a sample obtained from a subject at risk of developing an infection with a probe to detect the level of a gene expression product of at least one gene of Tables 4 and 5; measuring the presence or intensity of a signal which indicates the presence or level of the gene expression product in the sample; wherein a decrease in the level of a gene expression product of a gene of Table 4 relative to a reference level indicates the subject has a higher risk of having or developing an infection and an increase in the level of a gene expression product of a gene of Table 5 relative to a reference level indicates the subject has a higher risk of having or developing an infection. In one aspect, described herein is a method of identifying a subject in need of treatment for infection, the method comprising: measuring the level of a gene expression product of at least one gene of Tables 4 and 5 in a test sample obtained from a subject; and identifying the subject as being in need of treatment for infection when the level of a gene expression product of a gene of Table 4 is decreased relative to a reference level and the level of a gene expression product of a gene of Table 5 is increased relative to a reference level. In one aspect, described herein is a method of determining if a subject is at risk for infection, the method comprising: providing a sample obtained from the subject; measuring the level of a gene expression product of at least one gene of Tables 4 and 5 in the sample; comparing the level of the gene expression product in the sample to a reference level of the gene expression product; determining that the subject is at risk for infection when the level of a gene expression product of a gene of Table 4 is decreased relative to a reference level and the level of a gene expression product of a gene of Table 5 is increased relative to a reference level; and determining that the subject is not at risk for infection when the level of a gene expression product of a gene of Table 4 is not decreased relative to a reference level and the level of a gene expression product of a gene of Table 5 is not increased relative to a reference level.

In one aspect, described herein is a method of determining the efficacy of a treatment for infection, the method comprising: (a) measuring the level of a gene expression product of at least one gene of Tables 4 and 5 in a test sample obtained from a subject before administration of the treatment; (b) measuring the level of the gene expression product in a test sample obtained from a subject after administration of the treatment; and (c) determining that the treatment is effective when the level of a gene expression product of a gene of Table 4 measured in step (b) is not decreased relative to the level measured in step (a) and the level of a gene expression product of a gene of Table 5 measured in step (b) is not increased relative to the level measured in step (a). In some embodiments, the treatment for infection is an anti-sepsis treatment.

In one aspect, described herein is a method of treatment for infection comprising; measuring the level of a gene expression product of at least one gene of Tables 4 and 5 in a test sample obtained from a subject; treating the subject with a treatment selected from the group consisting of: antibiotics; extended courses of antibiotics; immunotherapy; and LPS removal; when the level of a gene expression product of a gene of Table 4 is decreased relative to a reference level and the level of a gene expression product of a gene of Table 5 is increased relative to a reference level. In one aspect, described herein is a method of treatment for infection comprising; administering a treatment selected from the group consisting of: antibiotics; extended courses of antibiotics; immunotherapy; and LPS removal; to a subject determined to have a level of a gene expression product of a gene of Table 4 that is decreased relative to a reference level or a level of a gene expression product of a gene of Table 5 that is increased relative to a reference level.

In some embodiments of any aspect described herein, the subject in need of treatment for infection and/or identified as being at risk of having or developing infection, is a subject in need of treatment for multiple infections and/or identified as being at risk of having or developing multiple infections. As used herein, “multiple infections” can refer to either infection with multiple organisms or multiple episodes of infection (e.g. with the same or different microbes). In some embodiments of any aspect described herein, the subject in need of treatment for infection and/or identified as being at risk of having or developing infection, is a subject in need of treatment for multiple infection episodes and/or identified as being at risk of having or developing multiple infection episodes. Non-limiting examples of microbes that can cause and/or contribute to an infection as described herein can include Gram-negative bacteria; Staphylococcus spp.; Staphylococcus aureus; coagulase-negative Staphylococci; Enterococcus spp.; Candida spp. Escherichia coli; Enterobacter spp.; Klebsiella pneumonia; Acinetobacter spp.; Pseudomonas aeruginosa; Streptococcus pneumonia; Streptococcus viridans; Gram-positive bacteria; Serratia marcescens; Hemophilus influenza; Stenotrophomonas spp.; Proteus; Aspergillus; Neisseria; Clostridium sp.; Bacteroides sp; fungi; cytomegalovirus; and herpes virii.

In certain embodiments the assays, methods, and systems are directed to determination and/or measurement of the expression level of a gene product of at least two genes in a biological sample of a subject, i.e. at least two genes, at least three genes, at least four genes, at least five genes, at least six genes, at least seven genes, at least eight genes, or more genes, or any number of genes selected from any in a combination of Table 4 and Table 5 as described herein. In some embodiments, one looks at a group of genes where some increase in expression and others decrease in expression. In some embodiments, the expression level of a gene product of the same number of genes from each of Tables 4 and 5 is determined, e.g. two genes from each table. In some embodiments, the expression level of a gene product of different numbers of genes from each of Tables 1 and 2 is determined, e.g. two genes from Table 4 and two genes from Table 5 or 1 gene from Table 4 and 2 genes from Table 5. In some embodiments, the expression level overall for the group shows a pattern change, i.e. some genes overexpress, some underexpress. In some embodiments, the overall change is statistically significant.

TABLE 4 Infection Susceptibility Marker Genes which are Downregulated in Subjects with increased susceptibility to infection Gene NCBI Reference No: MDFIC 29969 CCND2 894 OSBPL8 114882 DCAF7 10238 TMEM50B 757 GOLGA8A 23015 GOLGA8B 440270 SMARCA4 6597 WHSC1L1 54904 LOC101928343 101928343 LINC00869 57234 PDLIM5 10611 GATAD2B 57459 ZSCAN30 100101467 ALDH1A1 216 ALDH1A2 8854 ALDH5A1 7915 ALDH6A1 4329 ALDH7A1 501

TABLE 5 Infection Susceptibility Marker Genes which are Upregulated in Subjects with increased susceptibility to infection Gene NCBI Reference No: THBS1 7057 ARHGEF7 8874 NFKB2 4791 MAX 4149 ALDH3B1 221

The gene names listed in Tables 4 and 5 are common names. NCBI Gene ID numbers for each of the genes listed in Tables 4 and 5 can be obtained for a number of species by searching the “Gene” Database of the NCBI (available on the World Wide Web at ncbi.nlm.nih.gov/) using the common name as the query and selecting the first returned gene for the desired species. The NCBI Reference numbers provided in Tables 4 and 5 are those for the Homo sapiens genes.

In subjects at risk of having or developing infection and/or in need of treatment for infection, the marker genes listed in Table 4 can be downregulated and those in Table 5 can be upregulated, e.g. for marker genes listed in Table 4, if the measured marker gene expression in a subject is lower as compared to a reference level of that marker gene's expression, then the subject is identified as having an increased risk of having and/or developing infection and/or being in need of treatment for infection. Likewise, for marker genes listed in Table 5, if the measured marker gene expression in a subject is higher by as compared to a reference level of that marker gene's expression, then the subject is identified as having an increased risk of having and/or developing infection and/or being in need of treatment for infection. In some embodiments, one looks at a statistically significant change. However, even if a few genes in a group do not differ from normal, a subject can be identified as having an increased risk of having and/or developing infection and/or being in need of treatment for infection if the overall change of the group shows a significant change, preferably a statistically significant change.

In certain embodiments marker genes in Table 5 are upregulated in subjects having an increased risk of having and/or developing infection and/or being in need of treatment for infection. If the level of a gene expression product of a marker gene in Table 5 is higher than a reference level of that marker gene, the subject is more likely to have an increased risk of having and/or developing infection and/or be in need of treatment for infection. The level of a gene expression product of a marker gene in Table 5 which is higher than a reference level of that marker gene by at least about 10% than the reference amount, at least about 20%, at least about 30%, at least about 40%, at least about 50%, at least about 80%, at least about 100%, at least about 200%, at least about 300%, at least about 500% or at least about 1000% or more, is indicative that the subject has an increased risk of having and/or developing infection and/or is in need of treatment for infection.

In certain embodiments marker genes in Table 4 are downregulated in subjects having an increased risk of having and/or developing infection and/or being in need of treatment for infection. If the level of a gene expression product of a marker gene in Table 4 is less than a reference level of that marker gene, the subject is more likely to have an increased risk of having and/or developing infection and/or be in need of treatment for infection. The level of a gene expression product of a marker gene in Table 4 which is lower than a reference level of that marker gene by at least about 10% than the reference amount, at least about 20%, at least about 30%, at least about 40%, at least about 50%, at least about 60%, at least about 70%, at least about 80%, at least about 90%, or at least about 95%, about 98%, about 99% or 100%, including all the percentages between 10-100% is indicative that the subject has an increased risk of having and/or developing infection and/or is in need of treatment for infection.

In certain embodiments a subject is indicated to have an increased risk of having and/or developing infection and/or be in need of treatment for infection. if the expression level of one or more marker genes in a sample obtained from a subject differs from the expression level in a reference sample by a statistically significant amount.

In some embodiments, the expression level of a gene expression product of at least two genes of Tables 4 and 5 are measured. In some embodiments, the expression level of a gene expression product of at least three genes of Tables 4 and 5 are measured. In some embodiments, the expression level of a gene expression product of at least four genes of Tables 4 and 5 are measured. In some embodiments, the expression level of a gene expression product of at least five genes of Tables 4 and 5 are measured. In some embodiments, the expression level of a gene expression product of at least six genes of Tables 4 and 5 are measured. In some embodiments, the expression level of a gene expression product of at least seven genes of Tables 4 and 5 are measured. In some embodiments, the expression level of a gene expression product of at least eight genes of Tables 4 and 5 are measured. In some embodiments, the expression level of a gene expression product of at least nine genes of Tables 4 and 5 are measured. In some embodiments, the expression level of a gene expression product of at least ten genes of Tables 4 and 5 are measured.

In some embodiments, the level of a gene expression product of at least one gene selected from the group consisting of: THBS1; ARHGEF7; MDFIC; CCND2; OSBPL8; DCAF7; TMEM50B; GOLGA8A and/or GOLGA8B; SMARCA4; WHSC1L1; LOC101928343; and LINC00869. In some embodiments, the level of a gene expression product of each of THBS1; ARHGEF7; MDFIC; CCND2; OSBPL8; DCAF7; TMEM50B; GOLGA8A and/or GOLGA8B; SMARCA4; WHSC1L1; LOC101928343; and LINC00869 is measured. In some embodiments, the sample is a blood or plasma sample.

In some embodiments, the level of a gene expression product of at least one gene selected from the group consisting of: CCND2; THBS1; MDFIC; SMARCA4; WHSC1L1; TMEM50B; DCAF7; and OSBPL8 is measured. In some embodiments, the level of a gene expression product of each of CCND2; THBS1; MDFIC; SMARCA4; WHSC1L1; TMEM50B; DCAF7; and OSBPL8 is measured. In some embodiments, the sample is a blood or plasma sample. In some embodiments, the subject is at least 16 years of age or older.

In some embodiments, the level of a gene expression product of at least one gene selected from the group consisting of: NFKB2; MAX; PDLIM5; GATAD2B; and ZSCAN30 is measured. In some embodiments, the level of a gene expression product of each of NFKB2; MAX; PDLIM5; GATAD2B; and ZSCAN30 is measured. In some embodiments, the sample is a blood or plasma sample. In some embodiments, the subject is 15 years of age or younger.

In some embodiments, the level of a gene expression product of at least one gene selected from the group consisting of: ALDH1A1; ALDH1A2; ALDH3B1; ALDH5A1; ALDH6A1; and ALDH7A1 is measured. In some embodiments, the level of a gene expression product of each of ALDH1A1; ALDH1A2; ALDH3B1; ALDH5A1; ALDH6A1; and ALDH7A1 is measured. In some embodiments, the sample is a muscle sample.

In some embodiments of any of the aspects described herein, information on the Total Body Surface Area (TBSA) burns, age and inhalation status (yes or no) can also be used in conjunction with the gene panel(s) described herein to improve prognosis and/or treatment. In one aspect, the assay or method can further comprise determining the values of total body surface area (TBSA) burns, age, and/or inhalation status; wherein an increase in any of the preceding values indicates an increased risk of the subject having or developing infection. One of skill in the art can readily determine such values, e.g., as part of a physical examination and/or triage process.

In some embodiments of the various aspects described herein, the assay or method can further comprise multiplying each gene expression value measured, and optionally, the total body surface area (TBSA) burns, age, and/or inhalation status values, by a coefficient and adding the resulting products to yield a risk value. Such coefficients adjust the various values to reflect their relative predictive weight and/or provide a risk value that falls upon a desired scale (e.g. 1 to 10). As used herein “risk value” refers to a value calculated by adding two or more gene expression values, and optionally, the total body surface area (TBSA) burns, age, and/or inhalation status values. In some embodiments, the values can first be multiplied by coefficients before the addition step.

In some embodiments, the coefficient can be about the coefficient value given for a particular value in Table 7. In some embodiments, a risk value of greater than about −1.1912 indicates the subject is at risk of having or developing infection and/or is in need of treatment for infection. This baseline coefficient is equal to zero for all the values, e.g., meaning that the population of the baseline was someone age 0, TBSA 0, no inhal, and 0 expression value for all the genes.

In some embodiments, the methods and assays described herein include (a) transforming the gene expression product into a detectable gene target; (b) measuring the amount of the detectable gene target; and (c) comparing the amount of the detectable gene target to an amount of a reference, wherein if the amount of the detectable gene target is statistically different from that of the amount of the reference level, the subject is identified as having an increased risk of having and/or developing infection and/or being in need of treatment for infection. As used herein, the term “transforming” or “transformation” refers to changing an object or a substance, e.g., biological sample, nucleic acid or protein, into another substance. The transformation can be physical, biological or chemical. Exemplary physical transformation includes, but not limited to, pre-treatment of a biological sample, e.g., from whole blood to blood serum by differential centrifugation. A biological/chemical transformation can involve at least one enzyme and/or a chemical reagent in a reaction. For example, a DNA sample can be digested into fragments by one or more restriction enzyme, or an exogenous molecule can be attached to a fragmented DNA sample with a ligase. In some embodiments, a DNA sample can undergo enzymatic replication, e.g., by polymerase chain reaction (PCR).

Transformation, measurement, and/or detection of a target molecule, e.g. a mRNA or polypeptide of a gene of Tables 4 or 5 can comprise contacting a sample obtained from a subject with a reagent (e.g. a detection reagent) which is specific for the target, e.g., a TMEM50B-specific reagent. In some embodiments, the target-specific reagent is detectably labeled. In some embodiments, the target-specific reagent is capable of generating a detectable signal. In some embodiments, the target-specific reagent generates a detectable signal when the target molecule is present.

Methods to measure gene expression products are well known to a skilled artisan. Such methods to measure gene expression products, e.g., protein level, include ELISA (enzyme linked immunosorbent assay), western blot, immunoprecipitation, and immunofluorescence using detection reagents such as an antibody or protein binding agents. Alternatively, a peptide can be detected in a subject by introducing into a subject a labeled anti-peptide antibody and other types of detection agent. For example, the antibody can be labeled with a detectable marker whose presence and location in the subject is detected by standard imaging techniques.

For example, antibodies for TMEM50B are commercially available and can be used for the purposes of the invention to measure protein expression levels, e.g. anti-TMEM50B (Cat. No. ab107741; Abcam, Cambridge Mass.). Alternatively, since the amino acid sequences for the marker genes are known and publically available at NCBI website, one of skill in the art can raise their own antibodies against these polypeptides of interest for the purpose of the invention. The amino acid sequences of the polypeptides described herein, have been assigned NCBI accession numbers for different species such as human, mouse and rat.

In some embodiments, immunohistochemistry (“IHC”) and immunocytochemistry (“ICC”) techniques can be used. IHC is the application of immunochemistry to tissue sections, whereas ICC is the application of immunochemistry to cells or tissue imprints after they have undergone specific cytological preparations such as, for example, liquid-based preparations. Immunochemistry is a family of techniques based on the use of an antibody, wherein the antibodies are used to specifically target molecules inside or on the surface of cells. The antibody typically contains a marker that will undergo a biochemical reaction, and thereby experience a change of color, upon encountering the targeted molecules. In some instances, signal amplification can be integrated into the particular protocol, wherein a secondary antibody, that includes the marker stain or marker signal, follows the application of a primary specific antibody.

In some embodiments, the assay can be a Western blot analysis. Alternatively, proteins can be separated by two-dimensional gel electrophoresis systems. Two-dimensional gel electrophoresis is well known in the art and typically involves iso-electric focusing along a first dimension followed by SDS-PAGE electrophoresis along a second dimension. These methods also require a considerable amount of cellular material. The analysis of 2D SDS-PAGE gels can be performed by determining the intensity of protein spots on the gel, or can be performed using immune detection. In other embodiments, protein samples are analyzed by mass spectroscopy.

Immunological tests can be used with the methods and assays described herein and include, for example, competitive and non-competitive assay systems using techniques such as Western blots, radioimmunoassay (RIA), ELISA (enzyme linked immunosorbent assay), “sandwich” immunoassays, immunoprecipitation assays, immunodiffusion assays, agglutination assays, e.g. latex agglutination, complement-fixation assays, immunoradiometric assays, fluorescent immunoassays, e.g. FIA (fluorescence-linked immunoassay), chemiluminescence immunoassays (CLIA), electrochemiluminescence immunoassay (ECLIA, counting immunoassay (CIA), lateral flow tests or immunoassay (LFIA), magnetic immunoassay (MIA), and protein A immunoassays. Methods for performing such assays are known in the art, provided an appropriate antibody reagent is available. In some embodiment, the immunoassay can be a quantitative or a semi-quantitative immunoassay.

An immunoassay is a biochemical test that measures the concentration of a substance in a biological sample, typically a fluid sample such as urine, using the interaction of an antibody or antibodies to its antigen. The assay takes advantage of the highly specific binding of an antibody with its antigen. For the methods and assays described herein, specific binding of the target polypeptides with respective proteins or protein fragments, or an isolated peptide, or a fusion protein described herein occurs in the immunoassay to form a target protein/peptide complex. The complex is then detected by a variety of methods known in the art. An immunoassay also often involves the use of a detection antibody.

Enzyme-linked immunosorbent assay, also called ELISA, enzyme immunoassay or EIA, is a biochemical technique used mainly in immunology to detect the presence of an antibody or an antigen in a sample. The ELISA has been used as a diagnostic tool in medicine and plant pathology, as well as a quality control check in various industries.

In one embodiment, an ELISA involving at least one antibody with specificity for the particular desired antigen can also be performed. A known amount of sample and/or antigen is immobilized on a solid support (usually a polystyrene micro titer plate). Immobilization can be either non-specific (e.g., by adsorption to the surface) or specific (e.g. where another antibody immobilized on the surface is used to capture antigen or a primary antibody). After the antigen is immobilized, the detection antibody is added, forming a complex with the antigen. The detection antibody can be covalently linked to an enzyme, or can itself be detected by a secondary antibody which is linked to an enzyme through bio-conjugation. Between each step the plate is typically washed with a mild detergent solution to remove any proteins or antibodies that are not specifically bound. After the final wash step the plate is developed by adding an enzymatic substrate to produce a visible signal, which indicates the quantity of antigen in the sample. Older ELISAs utilize chromogenic substrates, though newer assays employ fluorogenic substrates with much higher sensitivity.

In another embodiment, a competitive ELISA is used. Purified antibodies that are directed against a target polypeptide or fragment thereof are coated on the solid phase of multi-well plate, i.e., conjugated to a solid surface. A second batch of purified antibodies that are not conjugated on any solid support is also needed. These non-conjugated purified antibodies are labeled for detection purposes, for example, labeled with horseradish peroxidase to produce a detectable signal. A sample (e.g., a blood sample) from a subject is mixed with a known amount of desired antigen (e.g., a known volume or concentration of a sample comprising a target polypeptide) together with the horseradish peroxidase labeled antibodies and the mixture is then are added to coated wells to form competitive combination. After incubation, if the polypeptide level is high in the sample, a complex of labeled antibody reagent-antigen will form. This complex is free in solution and can be washed away. Washing the wells will remove the complex. Then the wells are incubated with TMB (3, 3′, 5, 5′-tetramethylbenzidene) color development substrate for localization of horseradish peroxidase-conjugated antibodies in the wells. There will be no color change or little color change if the target polypeptide level is high in the sample. If there is little or no target polypeptide present in the sample, a different complex in formed, the complex of solid support bound antibody reagents-target polypeptide. This complex is immobilized on the plate and is not washed away in the wash step. Subsequent incubation with TMB will produce much color change. Such a competitive ELSA test is specific, sensitive, reproducible and easy to operate.

There are other different forms of ELISA, which are well known to those skilled in the art. The standard techniques known in the art for ELISA are described in “Methods in Immunodiagnosis”, 2nd Edition, Rose and Bigazzi, eds. John Wiley & Sons, 1980; and Oellerich, M. 1984, J. Clin. Chem. Clin. Biochem. 22:895-904. These references are hereby incorporated by reference in their entirety.

In one embodiment, the levels of a polypeptide in a sample can be detected by a lateral flow immunoassay test (LFIA), also known as the immunochromatographic assay, or strip test. LFIAs are a simple device intended to detect the presence (or absence) of antigen, e.g. a polypeptide, in a fluid sample. There are currently many LFIA tests are used for medical diagnostics either for home testing, point of care testing, or laboratory use. LFIA tests are a form of immunoassay in which the test sample flows along a solid substrate via capillary action. After the sample is applied to the test strip it encounters a colored reagent (generally comprising antibody specific for the test target antigen) bound to microparticles which mixes with the sample and transits the substrate encountering lines or zones which have been pretreated with another antibody or antigen. Depending upon the level of target polypeptides present in the sample the colored reagent can be captured and become bound at the test line or zone. LFIAs are essentially immunoassays adapted to operate along a single axis to suit the test strip format or a dipstick format. Strip tests are extremely versatile and can be easily modified by one skilled in the art for detecting an enormous range of antigens from fluid samples such as urine, blood, water, and/or homogenized tissue samples etc. Strip tests are also known as dip stick test, the name bearing from the literal action of “dipping” the test strip into a fluid sample to be tested. LFIA strip tests are easy to use, require minimum training and can easily be included as components of point-of-care test (POCT) diagnostics to be use on site in the field. LFIA tests can be operated as either competitive or sandwich assays. Sandwich LFIAs are similar to sandwich ELISA. The sample first encounters colored particles which are labeled with antibodies raised to the target antigen. The test line will also contain antibodies to the same target, although it may bind to a different epitope on the antigen. The test line will show as a colored band in positive samples. In some embodiments, the lateral flow immunoassay can be a double antibody sandwich assay, a competitive assay, a quantitative assay or variations thereof. Competitive LFIAs are similar to competitive ELISA. The sample first encounters colored particles which are labeled with the target antigen or an analogue. The test line contains antibodies to the target/its analogue. Unlabelled antigen in the sample will block the binding sites on the antibodies preventing uptake of the colored particles. The test line will show as a colored band in negative samples. There are a number of variations on lateral flow technology. It is also possible to apply multiple capture zones to create a multiplex test.

The use of “dip sticks” or LFIA test strips and other solid supports have been described in the art in the context of an immunoassay for a number of antigen biomarkers. U.S. Pat. Nos. 4,943,522; 6,485,982; 6,187,598; 5,770,460; 5,622,871; 6,565,808, U.S. patent application Ser. No. 10/278,676; U.S. Ser. No. 09/579,673 and U.S. Ser. No. 10/717,082, which are incorporated herein by reference in their entirety, are non-limiting examples of such lateral flow test devices. Examples of patents that describe the use of “dip stick” technology to detect soluble antigens via immunochemical assays include, but are not limited to U.S. Pat. Nos. 4,444,880; 4,305,924; and 4,135,884; which are incorporated by reference herein in their entireties. The apparatuses and methods of these three patents broadly describe a first component fixed to a solid surface on a “dip stick” which is exposed to a solution containing a soluble antigen that binds to the component fixed upon the “dip stick,” prior to detection of the component-antigen complex upon the stick. It is within the skill of one in the art to modify the teachings of this “dip stick” technology for the detection of polypeptides using antibody reagents as described herein.

Other techniques can be used to detect the level of a polypeptide in a sample. One such technique is the dot blot, and adaptation of Western blotting (Towbin et at., Proc. Nat. Acad. Sci. 76:4350 (1979)). In a Western blot, the polypeptide or fragment thereof can be dissociated with detergents and heat, and separated on an SDS-PAGE gel before being transferred to a solid support, such as a nitrocellulose or PVDF membrane. The membrane is incubated with an antibody reagent specific for the target polypeptide or a fragment thereof. The membrane is then washed to remove unbound proteins and proteins with non-specific binding. Detectably labeled enzyme-linked secondary or detection antibodies can then be used to detect and assess the amount of polypeptide in the sample tested. The intensity of the signal from the detectable label corresponds to the amount of enzyme present, and therefore the amount of polypeptide. Levels can be quantified, for example by densitometry.

In some embodiments, the level of, e.g., TMEM50B, can be measured, by way of non-limiting example, by Western blot; immunoprecipitation; enzyme-linked immunosorbent assay (ELISA); radioimmunological assay (RIA); sandwich assay; fluorescence in situ hybridization (FISH); immunohistological staining; radioimmunometric assay; immunofluoresence assay; mass spectroscopy and/or immunoelectrophoresis assay.

In certain embodiments, the gene expression products as described herein can be instead determined by determining the level of messenger RNA (mRNA) expression of the genes described herein, e.g. a marker gene of Table 4 or 5. Such molecules can be isolated, derived, or amplified from a biological sample, such as a blood sample. Techniques for the detection of mRNA expression are known by persons skilled in the art, and can include but not limited to, PCR procedures, RT-PCR, quantitative RT-PCR Northern blot analysis, differential gene expression, RNA protection assay, microarray based analysis, next-generation sequencing; hybridization methods, etc.

In general, the PCR procedure describes a method of gene amplification which is comprised of (i) sequence-specific hybridization of primers to specific genes or sequences within a nucleic acid sample or library, (ii) subsequent amplification involving multiple rounds of annealing, elongation, and denaturation using a thermostable DNA polymerase, and (iii) screening the PCR products for a band of the correct size. The primers used are oligonucleotides of sufficient length and appropriate sequence to provide initiation of polymerization, i.e. each primer is specifically designed to be complementary to a strand of the genomic locus to be amplified. In an alternative embodiment, mRNA level of gene expression products described herein can be determined by reverse-transcription (RT) PCR and by quantitative RT-PCR (QRT-PCR) or real-time PCR methods. Methods of RT-PCR and QRT-PCR are well known in the art.

In some embodiments, the level of an mRNA can be measured by a quantitative sequencing technology, e.g. a quantitative next-generation sequence technology. Methods of sequencing a nucleic acid sequence are well known in the art. Briefly, a sample obtained from a subject can be contacted with one or more primers which specifically hybridize to a single-strand nucleic acid sequence flanking the target gene sequence and a complementary strand is synthesized. In some next-generation technologies, an adaptor (double or single-stranded) is ligated to nucleic acid molecules in the sample and synthesis proceeds from the adaptor or adaptor compatible primers. In some third-generation technologies, the sequence can be determined, e.g. by determining the location and pattern of the hybridization of probes, or measuring one or more characteristics of a single molecule as it passes through a sensor (e.g. the modulation of an electrical field as a nucleic acid molecule passes through a nanopore). Exemplary methods of sequencing include, but are not limited to, Sanger sequencing, dideoxy chain termination, high-throughput sequencing, next generation sequencing, 454 sequencing, SOLiD sequencing, polony sequencing, Illumina sequencing, Ion Torrent sequencing, sequencing by hybridization, nanopore sequencing, Helioscope sequencing, single molecule real time sequencing, RNAP sequencing, and the like. Methods and protocols for performing these sequencing methods are known in the art, see, e.g. “Next Generation Genome Sequencing” Ed. Michal Janitz, Wiley-VCH; “High-Throughput Next Generation Sequencing” Eds. Kwon and Ricke, Humanna Press, 2011; and Sambrook et al., Molecular Cloning: A Laboratory Manual (4 ed.), Cold Spring Harbor Laboratory Press, Cold Spring Harbor, N.Y., USA (2012); which are incorporated by reference herein in their entireties.

The nucleic acid sequences of the genes described herein, e.g., the marker genes of Tables 4 or 5, have been assigned NCBI accession numbers for different species such as human, mouse and rat. Accordingly, a skilled artisan can design an appropriate primer based on the known sequence for determining the mRNA level of the respective gene.

Nucleic acid and ribonucleic acid (RNA) molecules can be isolated from a particular biological sample using any of a number of procedures, which are well-known in the art, the particular isolation procedure chosen being appropriate for the particular biological sample. For example, freeze-thaw and alkaline lysis procedures can be useful for obtaining nucleic acid molecules from solid materials; heat and alkaline lysis procedures can be useful for obtaining nucleic acid molecules from urine; and proteinase K extraction can be used to obtain nucleic acid from blood (Roiff, A et al. PCR: Clinical Diagnostics and Research, Springer (1994)).

In some embodiments, one or more of the reagents (e.g. an antibody reagent and/or nucleic acid probe) described herein can comprise a detectable label and/or comprise the ability to generate a detectable signal (e.g. by catalyzing reaction converting a compound to a detectable product). Detectable labels can comprise, for example, a light-absorbing dye, a fluorescent dye, or a radioactive label. Detectable labels, methods of detecting them, and methods of incorporating them into reagents (e.g. antibodies and nucleic acid probes) are well known in the art.

In some embodiments, detectable labels can include labels that can be detected by spectroscopic, photochemical, biochemical, immunochemical, electromagnetic, radiochemical, or chemical means, such as fluorescence, chemifluoresence, or chemiluminescence, or any other appropriate means. The detectable labels used in the methods described herein can be primary labels (where the label comprises a moiety that is directly detectable or that produces a directly detectable moiety) or secondary labels (where the detectable label binds to another moiety to produce a detectable signal, e.g., as is common in immunological labeling using secondary and tertiary antibodies). The detectable label can be linked by covalent or non-covalent means to the reagent. Alternatively, a detectable label can be linked such as by directly labeling a molecule that achieves binding to the reagent via a ligand-receptor binding pair arrangement or other such specific recognition molecules. Detectable labels can include, but are not limited to radioisotopes, bioluminescent compounds, chromophores, antibodies, chemiluminescent compounds, fluorescent compounds, metal chelates, and enzymes.

In other embodiments, the detection reagent is label with a fluorescent compound. When the fluorescently labeled reagent is exposed to light of the proper wavelength, its presence can then be detected due to fluorescence. In some embodiments, a detectable label can be a fluorescent dye molecule, or fluorophore including, but not limited to fluorescein, phycoerythrin, phycocyanin, o-phthaldehyde, fluorescamine, Cy3™, Cy5™, allophycocyanine, Texas Red, peridenin chlorophyll, cyanine, tandem conjugates such as phycoerythrin-Cy5™, green fluorescent protein, rhodamine, fluorescein isothiocyanate (FITC) and Oregon Green™, rhodamine and derivatives (e.g., Texas red and tetrarhodimine isothiocynate (TRITC)), biotin, phycoerythrin, AMCA, CyDyes™, 6-carboxyfhiorescein (commonly known by the abbreviations FAM and F), 6-carboxy-2′,4′,7′,4,7-hexachlorofiuorescein (HEX), 6-carboxy-4′,5′-dichloro-2′,7′-dimethoxyfiuorescein (JOE or J), N,N,N′,N′-tetramethyl-6carboxyrhodamine (TAMRA or T), 6-carboxy-X-rhodamine (ROX or R), 5-carboxyrhodamine-6G (R6G5 or G5), 6-carboxyrhodamine-6G (R6G6 or G6), and rhodamine 110; cyanine dyes, e.g. Cy3, Cy5 and Cy7 dyes; coumarins, e.g umbelliferone; benzimide dyes, e.g. Hoechst 33258; phenanthridine dyes, e.g. Texas Red; ethidium dyes; acridine dyes; carbazole dyes; phenoxazine dyes; porphyrin dyes; polymethine dyes, e.g. cyanine dyes such as Cy3, Cy5, etc; BODIPY dyes and quinoline dyes. In some embodiments, a detectable label can be a radiolabel including, but not limited to ³H, ¹²⁵I, ³⁵S, ¹⁴C, ³²P, and ³³P. In some embodiments, a detectable label can be an enzyme including, but not limited to horseradish peroxidase and alkaline phosphatase. An enzymatic label can produce, for example, a chemiluminescent signal, a color signal, or a fluorescent signal. Enzymes contemplated for use to detectably label an antibody reagent include, but are not limited to, malate dehydrogenase, staphylococcal nuclease, delta-V-steroid isomerase, yeast alcohol dehydrogenase, alpha-glycerophosphate dehydrogenase, triose phosphate isomerase, horseradish peroxidase, alkaline phosphatase, asparaginase, glucose oxidase, beta-galactosidase, ribonuclease, urease, catalase, glucose-VI-phosphate dehydrogenase, glucoamylase and acetylcholinesterase. In some embodiments, a detectable label is a chemiluminescent label, including, but not limited to lucigenin, luminol, luciferin, isoluminol, theromatic acridinium ester, imidazole, acridinium salt and oxalate ester. In some embodiments, a detectable label can be a spectral colorimetric label including, but not limited to colloidal gold or colored glass or plastic (e.g., polystyrene, polypropylene, and latex) beads.

In some embodiments, detection reagents can also be labeled with a detectable tag, such as c-Myc, HA, VSV-G, HSV, FLAG, V5, HIS, or biotin. Other detection systems can also be used, for example, a biotin-streptavidin system. In this system, the antibodies immunoreactive (i. e. specific for) with the biomarker of interest is biotinylated. Quantity of biotinylated antibody bound to the biomarker is determined using a streptavidin-peroxidase conjugate and a chromagenic substrate. Such streptavidin peroxidase detection kits are commercially available, e. g. from DAKO; Carpinteria, Calif. A reagent can also be detectably labeled using fluorescence emitting metals such as ¹⁵²Eu, or others of the lanthanide series. These metals can be attached to the reagent using such metal chelating groups as diethylenetriaminepentaacetic acid (DTPA) or ethylene diaminetetraacetic acid (EDTA).

A level which is greater than a reference level can be a level which is greater by at least about 10%, at least about 20%, at least about 50%, at least about 100%, at least about 200%, at least about 300%, at least about 500%, at least about 1000%, or greater than the reference level. In some embodiments, a level which is greater than a reference level can be a level which is statistically significantly greater than the reference level. A level which is less than a reference level can be a level which is lower by at least about 10%, at least about 20%, at least about 50%, at least about 60%, at least about 70%, at least about 80%, at least about 90%, or less of the reference level. In some embodiments, a level which is less than a reference level can be a level which is statistically significantly less than the reference level.

In some embodiments, the reference can be a level of expression of the marker gene product in a normal healthy subject with no symptoms or signs of infection. For example, a normal healthy subject has no burn injury, no signs and/or symptoms of immunosuppression, no inhalation injury, and no detectable presence of a pathogen in the bloodstream. In some embodiments, the reference can also be a level of expression of the marker gene product in a control sample, a pooled sample of control individuals or a numeric value or range of values based on the same.

In some embodiments, the reference can be a level of a marker gene in a population of subjects who do not have or are not diagnosed as having, and/or do not exhibit signs or symptoms of infection and/or are not at risk of infection (e.g., they do not have a burn injury, immunosuppression, and/or inhalation injury). In some embodiments, the reference can also be a level of expression of a marker gene in a control sample, a pooled sample of control individuals or a numeric value or range of values based on the same. In some embodiments, the reference can be the level of a marker gene in a sample obtained from the same subject at an earlier point in time, e.g., the methods described herein can be used to determine if a subject's risk or likelihood of developing infection is increasing.

In some embodiments, the methods, assays, and systems described herein can further comprise a step of obtaining a test sample from a subject. In some embodiments, the subject can be a human subject. In some embodiments, the subject can be a subject in need of treatment for (e.g. having or diagnosed as having) infection, burn injury, immunosuppression, and/or inhalation injury. In some embodiments, the subject at risk of infection can be a subject at risk of multiple infection episodes, sepsis, and/or pneumonia. Additional non-limiting examples of subjects at risk of infection can include, patients who need major surgical procedures, patients with intubation or catheters, patients in the intensive care unit and with central lines, patients with blunt and penetrating trauma, patients with burn trauma, patients with diabetes and having diabetes foot and other infection complications, HIV patients and other conditions resulting in immunosuppression ie. cancer patients undergoing treatments, bone marrow transplants, transfusions, organ grafts.

The term “sample” or “test sample” as used herein denotes a sample taken or isolated from a biological organism, e.g., a blood or plasma sample from a subject. Exemplary biological samples include, but are not limited to, a biofluid sample; serum; plasma; urine; saliva; and/or tissue sample etc. The term also includes a mixture of the above-mentioned samples. The term “test sample” also includes untreated or pretreated (or pre-processed) biological samples. In some embodiments, a test sample can comprise cells from subject. In some embodiments, the test sample can be a blood sample. In some embodiments, the test sample can be a plasma sample.

The test sample can be obtained by removing a sample from a subject, but can also be accomplished by using previously sample (e.g. isolated at a prior timepoint and isolated by the same or another person). In addition, the test sample can be freshly collected or a previously collected sample.

In some embodiments, the test sample can be an untreated test sample. As used herein, the phrase “untreated test sample” refers to a test sample that has not had any prior sample pre-treatment except for dilution and/or suspension in a solution. Exemplary methods for treating a test sample include, but are not limited to, centrifugation, filtration, sonication, homogenization, heating, freezing and thawing, and combinations thereof. In some embodiments, the test sample can be a frozen test sample, e.g., a frozen tissue. The frozen sample can be thawed before employing methods, assays and systems described herein. After thawing, a frozen sample can be centrifuged before being subjected to methods, assays and systems described herein. In some embodiments, the test sample is a clarified test sample, for example, by centrifugation and collection of a supernatant comprising the clarified test sample. In some embodiments, a test sample can be a pre-processed test sample, for example, supernatant or filtrate resulting from a treatment selected from the group consisting of centrifugation, filtration, thawing, purification, and any combinations thereof. In some embodiments, the test sample can be treated with a chemical and/or biological reagent. Chemical and/or biological reagents can be employed to protect and/or maintain the stability of the sample, including biomolecules (e.g., nucleic acid and protein) therein, during processing. One exemplary reagent is a protease inhibitor, which is generally used to protect or maintain the stability of protein during processing. The skilled artisan is well aware of methods and processes appropriate for pre-processing of biological samples required for determination of the level of an expression product as described herein.

In certain embodiments, the subject may be exhibiting a sign or symptom of, e.g. burn injury, immunosuppression, and/or inhalation injury.

In some embodiments, the level of expression products of no more than 200 other genes is determined. In some embodiments, the level of expression products of no more than 100 other genes is determined. In some embodiments, the level of expression products of no more than 20 other genes is determined. In some embodiments, the level of expression products of no more than 10 other genes is determined.

In some embodiments of the various aspects, the expression level of a given gene, e.g., a marker gene of Table 4 or 5, can be normalized relative to the expression level of one or more reference genes or reference proteins, e.g. the expression level of a housekeeping gene.

In some embodiments of any of the various aspects, the method can further comprise a step of generating a report based on the detection of the one or more marker gene expression levels.

In some embodiments of any of the various aspects, the assay or method can further comprise the step of detecting the presence of susceptibility-associated SNPs or pathogen markers in the sample obtained from the subject. Susceptibility-associated SNPs and pathogen markers are well known in the art. See, e.g., for further discussion Netea M G, et al. Nature Immunology. 2012; 13:535-542; Bronkhorst MWGA, et al. British Journal of Surgery. 2013; 100:1818-1826; Jannes G, and De Vos D. Methods Mol Biol. 2006; 345:1-21; Pirnay J-P, et al. Crit Care. 2000; 4:255; Chang S-S, et al. PLoS One. 2013; 8:e62323; and Skvarc M, et al. Eur J Microbiol Immunol (Bp). 2013; 3:97-104; each of which is incorporated by reference herein in its entirety.

In some embodiments, the methods described herein relate to treating a subject having or diagnosed as having, e.g. burn injury, inhalation injury, or immunosuppression with a treatment for infection.

Subjects having burn injury can be identified by a physician using current methods of diagnosing burn injury. Symptoms and/or complications of burn injury which characterize these conditions and aid in diagnosis are well known in the art and include but are not limited to, pain, redness, blisters, and discoloration. A burn can be caused by, e.g., heat, friction, radiation, chemical exposure, or electrical exposure.

Subjects having inhalation injury can be identified by a physician using current methods of diagnosing inhalation injury. As used herein, “inhalation injury” refers to damage to the airways and/lungs by irritants and/or toxins in the air. Symptoms and/or complications of inhalation injury which characterize these conditions and aid in diagnosis are well known in the art and include but are not limited to, inflammation, hypoxia, and edema. Inhalation injury can be caused by, e.g., smoke, thermal injury, chlorine, phosgene, ammonia, sulfur mustard, chloramine, mustard gas, methyl isocyanate, and the like.

Subjects having immunosuppression can be identified by a physician using current methods of diagnosing immunosuppression. As used herein, “immunosuppression” refers to impairment of any component of cellular and/or humoral immunity. Symptoms and/or complications of immunosuppression which characterize these conditions and aid in diagnosis are well known in the art and include but are not limited to, fever, swelling, reduce urine output, infection, and the like. Tests that may aid in a diagnosis of, e.g. immunosuppression include, but are not limited to, assays of lymphocyte function, lymphocyte proliferation and expression of T cell surface antigens. Immunosuppression can be caused by, e.g., burn injury, inhalation injury, tumors, transplantation, HIV/AIDS, chemotherapy, or administration of immunosuppressants.

The compositions and methods described herein can be administered to a subject at increased risk of having or developing an infection. In some embodiments, the methods described herein comprise administering an effective amount of compositions described herein, to a subject in order to alleviate a symptom of infection. As used herein, “alleviating a symptom of an infection” is ameliorating any condition or symptom associated with the infection. As compared with an equivalent untreated control, such reduction is by at least 5%, 10%, 20%, 40%, 50%, 60%, 80%, 90%, 95%, 99% or more as measured by any standard technique. A variety of means for administering the compositions described herein to subjects are known to those of skill in the art. Such methods can include, but are not limited to oral, parenteral, intravenous, intramuscular, subcutaneous, transdermal, airway (aerosol), pulmonary, cutaneous, topical, or injection, or administration. Administration can be local or systemic.

The term “effective amount” as used herein refers to the amount of a treatment needed to alleviate at least one or more symptom of the disease or disorder, and relates to a sufficient amount of pharmacological composition to provide the desired effect. The term “therapeutically effective amount” therefore refers to an amount of a treatment that is sufficient to provide a particular anti-infective effect when administered to a typical subject. An effective amount as used herein, in various contexts, would also include an amount sufficient to delay the development of a symptom of the disease, alter the course of a symptom disease (for example but not limited to, slowing the progression of a symptom of the disease), or reverse a symptom of the disease. Thus, it is not generally practicable to specify an exact “effective amount”. However, for any given case, an appropriate “effective amount” can be determined by one of ordinary skill in the art using only routine experimentation.

Effective amounts, toxicity, and therapeutic efficacy can be determined by standard pharmaceutical procedures in cell cultures or experimental animals, e.g., for determining the LD50 (the dose lethal to 50% of the population) and the ED50 (the dose therapeutically effective in 50% of the population). The dosage can vary depending upon the dosage form employed and the route of administration utilized. The dose ratio between toxic and therapeutic effects is the therapeutic index and can be expressed as the ratio LD50/ED50. Compositions and methods that exhibit large therapeutic indices are preferred. A therapeutically effective dose can be estimated initially from cell culture assays. Also, a dose can be formulated in animal models to achieve a circulating plasma concentration range that includes the IC50 (i.e., the concentration of the active ingredient which achieves a half-maximal inhibition of symptoms) as determined in cell culture, or in an appropriate animal model. Levels in plasma can be measured, for example, by high performance liquid chromatography. The effects of any particular dosage can be monitored by a suitable bioassay, e.g., assay for bacterial titers, or the levels of marker genes as described herein, among others. The dosage can be determined by a physician and adjusted, as necessary, to suit observed effects of the treatment.

A number of treatments are know in the art for infection, e.g. for those at risk of infection or at risk of multiple infections. Non-limiting examples of such treatments can include anti-infectives; antibiotics; extended courses of antibiotics; immunotherapy; and LPS removal.

Anti-infective agents can include, for example, anti-viral and anti-fungal agents as well as agents for the treatment of parasitical infections. Exemplary anti-fungal agents can include, but are not limited to polyenes (e.g. amphotericin B; candicidin; fillipin, hamycin; natamycin; nystatin; and rimocidin), imidazoles (e.g., bifonazole; fentifconzaole; ketoconazole; etc), triazoles (e.g. albaconazole; fluconazole; ravuconazole; voriconazole, etc.), thiazoles (e.g. abafungin), allylamines (e.g. amorolfin; butenafine; naftifine; terbinafine), and echinocandins (e.g. anidulafungin; caspofungin; and micfungin). Exemplary anti-viral agents can include, but are not limited to: anti-VAP antibodies; amantadine; rimantadine; pleconaril; acyclovir; zidovudine; lamivudine; and fomivirsen. Additional non-limiting examples of anti-infect agent can include antioxidant therapies, e.g, Vitamin C, vitamin E, zinc, selenium, co-enzyme Q or other antioxidants supplements.

The term “antibiotic” is used herein to describe a compound or composition which decreases the viability of a microorganism, or which inhibits the growth or reproduction of a microorganism. As used in this disclosure, an antibiotic is further intended to include an antimicrobial, bacteriostatic, or bactericidal agent. Exemplary antibiotics include, but are not limited to penicillins, cephalosporins, penems, carbapenems, monobactams, aminoglycosides, sulfonamides, macrolides, tetracyclins, lincosides, quinolones, chloramphenicol, vancomycin, metronidazole, rifampin, isoniazid, spectinomycin, trimethoprim, sulfamethoxazole, and the like.

In some embodiments, a subject determined to be at risk of having or developing an infection (e.g. multiple infections) can be administered an extended course of antibiotics. An extended course of antibiotics can comprise administering the antibiotics before symptoms of infection are detected, administering multiple antibiotics, and/or administering antibiotics for a longer period of time than is standard for the particular formulation(s) being used.

As used herein, the term “immunotherapy” refers to the treatment of a subject with an agent that modulates the immune system, e.g. an antigen, adjuvant, immune system regulatory molecule, and/or antibody or antibody-based therapeutic. Exemplary immunotherapy agents include cytokines, IL-7, IL-2, IFN-gamma, and vaccines.

A further example of treatment for infection can comprise LPS removal, e.g., treating a subject's blood and/or plasma to reduce the level of active endotoxins (e.g. LPS) present in the blood and/or plasma. The endotoxins can be physically removed from the blood or neutralized without physically removing them.

In one aspect, described herein is a kit for performing any of the assays and/or methods described herein. In some embodiments, the kit can comprise a reagent specific for a gene expression product of one of the marker genes of Tables 4 or 5.

A kit is any manufacture (e.g., a package or container) comprising at least one reagent, e.g., an antibody reagent(s) or nucleic acid probe, for specifically detecting, e.g., a marker gene expression product or fragment thereof, the manufacture being promoted, distributed, or sold as a unit for performing the methods or assays described herein. When the kits, and methods described herein are used for diagnosis and/or treatment of infection, the reagents (e.g., detection probes) or systems can be selected such that a positive result is obtained in at least about 20%, at least about 40%, at least about 60%, at least about 80%, at least about 90%, at least about 95%, at least about 99% or in 100% of subjects who have or will develop infection.

In some embodiments, described herein is a kit for the detection of a marker gene expression product (e.g., a gene expression product of a gene of Table 4 or 5) in a sample, the kit comprising at least a first specific reagent as described herein which specifically binds the expression product, on a solid support and comprising a detectable label. The kits described herein include reagents and/or components that permit assaying the level of an expression product in a sample obtained from a subject (e.g., a biological sample obtained from a subject). The kits described herein can optionally comprise additional components useful for performing the methods and assays described herein.

A kit can further comprise devices and/or reagents for concentrating an expression product (e.g, a polypeptide) in a sample, e.g. a plasma sample. Thus, ultrafiltration devices permitting, e.g., protein concentration from plasma can also be included as a kit component.

Preferably, a diagnostic or prognostic kit for use with the methods and assays disclosed herein contains detection reagents for marker expression products. Such detection reagents comprise in addition to marker gene-specific reagents, for example, buffer solutions, labels or washing liquids etc. Furthermore, the kit can comprise an amount of a known nucleic acid and/or polypeptide, which can be used for a calibration of the kit or as an internal control. A diagnostic kit for the detection of an expression product can also comprise accessory ingredients like secondary affinity ligands, e.g., secondary antibodies, detection dyes and any other suitable compound or liquid necessary for the performance of an expression product detection method known to the person skilled in the art. Such ingredients are known to the person skilled in the art and may vary depending on the detection method carried out. Additionally, the kit may comprise an instruction leaflet and/or may provide information as to the relevance of the obtained results.

In some aspects, the invention described herein is directed to systems (and computer readable media for causing computer systems) for obtaining data from at least one sample obtained from at least one subject, the system comprising 1) a measuring module configured to receive the at least one sample and perform at least one analysis on the at least one sample to determine the level of a gene expression product of at least one marker gene of Table 4 or 5 in the sample; 2) a storage device configured to store data output from the determination module; and 3) a display module for displaying a content based in part on the data output from the determination module, wherein the content comprises a signal indicative of the level of the gene expression product.

In one embodiment, provided herein is a system comprising: (a) at least one memory containing at least one computer program adapted to control the operation of the computer system to implement a method that includes a measuring module configured to measure the level of a gene expression product of at least one marker gene of Table 4 or 5 in a test sample obtained from a subject; a storage module configured to store output data from the determination module; a comparison module adapted to compare the data stored on the storage module with a reference level, and to provide a retrieved content, and a display module for displaying whether the sample comprises a level of gene expression product which is significantly increased different (e.g. greater or less) than the reference expression level and/or displaying the relative level of the gene expression product and (b) at least one processor for executing the computer program (see FIG. 6).

The term “computer” can refer to any non-human apparatus that is capable of accepting a structured input, processing the structured input according to prescribed rules, and producing results of the processing as output. Examples of a computer include: a computer; a general purpose computer; a supercomputer; a mainframe; a super mini-computer; a mini-computer; a workstation; a micro-computer; a server; an interactive television; a hybrid combination of a computer and an interactive television; a tablet; and application-specific hardware to emulate a computer and/or software. A computer can have a single processor or multiple processors, which can operate in parallel and/or not in parallel. A computer also refers to two or more computers connected together via a network for transmitting or receiving information between the computers. An example of such a computer includes a distributed computer system for processing information via computers linked by a network.

The term “computer-readable medium” may refer to any storage device used for storing data accessible by a computer, as well as any other means for providing access to data by a computer. Examples of a storage-device-type computer-readable medium include: a magnetic hard disk; a floppy disk; an optical disk, such as a CD-ROM and a DVD; a magnetic tape; a memory chip. The term a “computer system” may refer to a system having a computer, where the computer comprises a computer-readable medium embodying software to operate the computer. The term “software” is used interchangeably herein with “program” and refers to prescribed rules to operate a computer. Examples of software include: software; code segments; instructions; computer programs; and programmed logic.

The computer readable storage media can be any available tangible media that can be accessed by a computer. Computer readable storage media includes volatile and nonvolatile, removable and non-removable tangible media implemented in any method or technology for storage of information such as computer readable instructions, data structures, program modules or other data. Computer readable storage media includes, but is not limited to, RAM (random access memory), ROM (read only memory), EPROM (erasable programmable read only memory), EEPROM (electrically erasable programmable read only memory), flash memory or other memory technology, CD-ROM (compact disc read only memory), DVDs (digital versatile disks) or other optical storage media, magnetic cassettes, magnetic tape, magnetic disk storage or other magnetic storage media, other types of volatile and non-volatile memory, and any other tangible medium which can be used to store the desired information and which can accessed by a computer including and any suitable combination of the foregoing.

Computer-readable data embodied on one or more computer-readable media may define instructions, for example, as part of one or more programs that, as a result of being executed by a computer, instruct the computer to perform one or more of the functions described herein, and/or various embodiments, variations and combinations thereof. Such instructions may be written in any of a plurality of programming languages, for example, Java, J #, Visual Basic, C, C #, C++, Fortran, Pascal, Eiffel, Basic, COBOL assembly language, R, SAS, and the like, or any of a variety of combinations thereof. The computer-readable media on which such instructions are embodied may reside on one or more of the components of either of a system, or a computer readable storage medium described herein, may be distributed across one or more of such components.

The computer-readable media may be transportable such that the instructions stored thereon can be loaded onto any computer resource to implement the aspects of the present invention discussed herein. In addition, it should be appreciated that the instructions stored on the computer-readable medium, described above, are not limited to instructions embodied as part of an application program running on a host computer. Rather, the instructions may be embodied as any type of computer code (e.g., software or microcode) that can be employed to program a computer to implement aspects of the present invention. The computer executable instructions may be written in a suitable computer language or combination of several languages. Basic computational biology methods are known to those of ordinary skill in the art and are described in, for example, Setubal and Meidanis et al., Introduction to Computational Biology Methods (PWS Publishing Company, Boston, 1997); Salzberg, Searles, Kasif, (Ed.), Computational Methods in Molecular Biology, (Elsevier, Amsterdam, 1998); Rashidi and Buehler, Bioinformatics Basics: Application in Biological Science and Medicine (CRC Press, London, 2000) and Ouelette and Bzevanis Bioinformatics: A Practical Guide for Analysis of Gene and Proteins (Wiley & Sons, Inc., 2nd ed., 2001).

Embodiments of the invention can be described through functional modules, which are defined by computer executable instructions recorded on computer readable media and which cause a computer to perform method steps when executed. The modules are segregated by function for the sake of clarity. However, it should be understood that the modules/systems need not correspond to discreet blocks of code and the described functions can be carried out by the execution of various code portions stored on various media and executed at various times. Furthermore, it should be appreciated that the modules can perform other functions, thus the modules are not limited to having any particular functions or set of functions.

The functional modules of certain embodiments of the invention include at minimum a measuring module, a storage module, a computing module, and a display module. The functional modules can be executed on one, or multiple, computers, or by using one, or multiple, computer networks. The measuring module has computer executable instructions to provide e.g., levels of expression products etc in computer readable form.

The measuring module can comprise any system for detecting a signal elicited from an assay to determine the level of a gene expression product as described above herein. In some embodiments, such systems can include an instrument, e.g., AU2700 (Beckman Coulter Brea, Calif.) as described herein for quantitative measurement of polypeptides or e.g., a real time PCR machine, e.g. a LIGHTCYCLER™ (Roche). In some embodiments, the measuring module can measure the intensity of a detectable signal from an assay indicating the level of a marker gene polypeptide in the test sample. In some embodiments, the assay can be an immunoassay. In some embodiments, the measuring module can measure the intensity of a detectable signal from a RT-PCR assay indicating the level of a marker gene RNA transcript in the test sample.

The information determined in the determination system can be read by the storage module. As used herein the “storage module” is intended to include any suitable computing or processing apparatus or other device configured or adapted for storing data or information. Examples of electronic apparatus suitable for use with the present invention include stand-alone computing apparatus, data telecommunications networks, including local area networks (LAN), wide area networks (WAN), Internet, Intranet, and Extranet, and local and distributed computer processing systems. Storage modules also include, but are not limited to: magnetic storage media, such as floppy discs, hard disc storage media, magnetic tape, optical storage media such as CD-ROM, DVD, electronic storage media such as RAM, ROM, EPROM, EEPROM and the like, general hard disks and hybrids of these categories such as magnetic/optical storage media. The storage module is adapted or configured for having recorded thereon, for example, sample name, biomolecule assayed and the level of said biomolecule. Such information may be provided in digital form that can be transmitted and read electronically, e.g., via the Internet, on diskette, via USB (universal serial bus) or via any other suitable mode of communication.

As used herein, “stored” refers to a process for encoding information on the storage module. Those skilled in the art can readily adopt any of the presently known methods for recording information on known media to generate manufactures comprising expression level information.

In some embodiments of any of the systems described herein, the storage module stores the output data from the determination module. In additional embodiments, the storage module stores reference information such as levels of marker gene expression products in healthy subjects and/or a population of healthy subjects.

The “computing module” can use a variety of available software programs and formats for computing the level of a gene expression product. Such algorithms are well established in the art. A skilled artisan is readily able to determine the appropriate algorithms based on the size and quality of the sample and type of data. The data analysis tools and equations described herein can be implemented in the computing module of the invention. In one embodiment, the computing module further comprises a comparison module, which compares the level of a gene expression product in a sample obtained from a subject as described herein with the mean value of the gene expression product in a population of healthy subjects and/or a population of patients unlikely to develop infection (FIG. 7). By way of an example, when the value of the gene expression product in a sample obtained from a subject is measured, a comparison module can compare or match the output data with the mean value of the expression product in a population of healthy subjects. In certain embodiments, the mean value of a gene expression product in a population of healthy subjects can be pre-stored in the storage module. In various embodiments, the comparison module can be configured using existing commercially-available or freely-available software for comparison purpose, and may be optimized for particular data comparisons that are conducted.

The computing and/or comparison module, or any other module of the invention, can include an operating system (e.g., UNIX) on which runs a relational database management system, a World Wide Web application, and a World Wide Web server. World Wide Web application includes the executable code necessary for generation of database language statements (e.g., Structured Query Language (SQL) statements). Generally, the executables will include embedded SQL statements. In addition, the World Wide Web application may include a configuration file which contains pointers and addresses to the various software entities that comprise the server as well as the various external and internal databases which must be accessed to service user requests. The Configuration file also directs requests for server resources to the appropriate hardware—as may be necessary should the server be distributed over two or more separate computers. In one embodiment, the World Wide Web server supports a TCP/IP protocol. Local networks such as this are sometimes referred to as “Intranets.” An advantage of such Intranets is that they allow easy communication with public domain databases residing on the World Wide Web (e.g., the GenBank or Swiss Pro World Wide Web site). In some embodiments users can directly access data (via Hypertext links for example) residing on Internet databases using a HTML interface provided by Web browsers and Web servers (FIG. 8).

The computing and/or comparison module provides a computer readable comparison result that can be processed in computer readable form by predefined criteria, or criteria defined by a user, to provide content based in part on the comparison result that may be stored and output as requested by a user using an output module, e.g., a display module.

In some embodiments, the content displayed on the display module can be the level of a gene expression product of at least one gene of Table 4 or 5 in the sample obtained from a subject. In some embodiments, the content displayed on the display module can be the relative level of a gene expression product in the sample obtained from a subject as compared to the mean level of the expression product in a population of healthy subjects. In some embodiments, if the computing module determines that the level of the gene expression product in the test sample obtained from a subject is different (in the direction indicated by Table 4 or 5, e.g., wherein a reduced level of a gene expression product of a gene of Table 4 indicates an increased risk of having or developing an infection and an increased level of a gene expression product of a gene of Table 5 indicates an increased risk of having or developing an infection) by a statistically significant amount than the reference level, the display module displays a signal indicating that the levels in the sample obtained from a subject vary from those of the reference level. In some embodiments, the signal indicates the subject is in need of treatment for infection. In some embodiments, the signal indicates the degree to which the level of the gene expression product in the sample obtained from a subject varies from the reference level. In some embodiments, the content displayed on the display module can indicate whether the subject has an increased likelihood of having or developing infection. In some embodiments, the content displayed on the display module can be a numerical value indicating one of these risks or probabilities. In such embodiments, the probability can be expressed in percentages or a fraction. For example, higher percentage or a fraction closer to 1 indicates a higher likelihood of a subject having or developing infection. In some embodiments, the content displayed on the display module can be single word or phrases to qualitatively indicate a risk or probability. For example, a word “unlikely” can be used to indicate a lower risk for having or developing infection, while “likely” can be used to indicate a high risk for having or developing infection.

In one embodiment of the invention, the content based on the computing and/or comparison result is displayed on a computer monitor. In one embodiment of the invention, the content based on the computing and/or comparison result is displayed through printable media. The display module can be any suitable device configured to receive from a computer and display computer readable information to a user. Non-limiting examples include, for example, general-purpose computers such as those based on Intel PENTIUM-type processor, Motorola PowerPC, Sun UltraSPARC, Hewlett-Packard PA-RISC processors, any of a variety of processors available from Advanced Micro Devices (AMD) of Sunnyvale, Calif., or any other type of processor, visual display devices such as flat panel displays, cathode ray tubes and the like, as well as computer printers of various types.

In one embodiment, a World Wide Web browser is used for providing a user interface for display of the content based on the computing/comparison result. It should be understood that other modules of the invention can be adapted to have a web browser interface. Through the Web browser, a user can construct requests for retrieving data from the computing/comparison module. Thus, the user will typically point and click to user interface elements such as buttons, pull down menus, scroll bars and the like conventionally employed in graphical user interfaces.

Systems and computer readable media described herein are merely illustrative embodiments of the invention for determining the level a gene expression product of at least one gene selected from Table 4 or 5 in a sample obtained from a subject, and therefore are not intended to limit the scope of the invention. Variations of the systems and computer readable media described herein are possible and are intended to fall within the scope of the invention.

For convenience, the meaning of some terms and phrases used in the specification, examples, and appended claims, are provided below. Unless stated otherwise, or implicit from context, the following terms and phrases include the meanings provided below. The definitions are provided to aid in describing particular embodiments, and are not intended to limit the claimed invention, because the scope of the invention is limited only by the claims. Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. If there is an apparent discrepancy between the usage of a term in the art and its definition provided herein, the definition provided within the specification shall prevail.

For convenience, certain terms employed herein, in the specification, examples and appended claims are collected here.

The terms “decrease”, “reduced”, “reduction”, or “inhibit” are all used herein to mean a decrease by a statistically significant amount. In some embodiments, “reduce,” “reduction” or “decrease” or “inhibit” typically means a decrease by at least 10% as compared to a reference level (e.g. the absence of a given treatment) and can include, for example, a decrease by at least about 10%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, at least about 98%, at least about 99%, or more. As used herein, “reduction” or “inhibition” does not encompass a complete inhibition or reduction as compared to a reference level. “Complete inhibition” is a 100% inhibition as compared to a reference level. A decrease can be preferably down to a level accepted as within the range of normal for an individual without a given disorder.

The terms “increased”, “increase”, “enhance”, or “activate” are all used herein to mean an increase by a statically significant amount. In some embodiments, the terms “increased”, “increase”, “enhance”, or “activate” can mean an increase of at least 10% as compared to a reference level, for example an increase of at least about 20%, or at least about 30%, or at least about 40%, or at least about 50%, or at least about 60%, or at least about 70%, or at least about 80%, or at least about 90% or up to and including a 100% increase or any increase between 10-100% as compared to a reference level, or at least about a 2-fold, or at least about a 3-fold, or at least about a 4-fold, or at least about a 5-fold or at least about a 10-fold increase, or any increase between 2-fold and 10-fold or greater as compared to a reference level. In the context of a marker or symptom, a “increase” is a statistically significant increase in such level.

As used herein, a “subject” means a human or animal. Usually the animal is a vertebrate such as a primate, rodent, domestic animal or game animal. Primates include chimpanzees, cynomologous monkeys, spider monkeys, and macaques, e.g., Rhesus. Rodents include mice, rats, woodchucks, ferrets, rabbits and hamsters. Domestic and game animals include cows, horses, pigs, deer, bison, buffalo, feline species, e.g., domestic cat, canine species, e.g., dog, fox, wolf, avian species, e.g., chicken, emu, ostrich, and fish, e.g., trout, catfish and salmon. In some embodiments, the subject is a mammal, e.g., a primate, e.g., a human. The terms, “individual,” “patient” and “subject” are used interchangeably herein.

Preferably, the subject is a mammal. The mammal can be a human, non-human primate, mouse, rat, dog, cat, horse, or cow, but is not limited to these examples. Mammals other than humans can be advantageously used as subjects that represent animal models of infection. A subject can be male or female.

A subject can be one who has been previously diagnosed with or identified as suffering from or having a condition in need of treatment (e.g. infection, burn injury, immunosuppression, and/or inhalation injury) or one or more complications related to such a condition, and optionally, have already undergone treatment for the condition or the one or more complications related to the condition. Alternatively, a subject can also be one who has not been previously diagnosed as having the condition or one or more complications related to the condition. For example, a subject can be one who exhibits one or more risk factors for the condition or one or more complications related to the condition or a subject who does not exhibit risk factors.

A “subject in need” of treatment for a particular condition can be a subject having that condition, diagnosed as having that condition, or at risk of developing that condition.

As used herein, the terms “protein” and “polypeptide” are used interchangeably herein to designate a series of amino acid residues, connected to each other by peptide bonds between the alpha-amino and carboxy groups of adjacent residues. The terms “protein”, and “polypeptide” refer to a polymer of amino acids, including modified amino acids (e.g., phosphorylated, glycated, glycosylated, etc.) and amino acid analogs, regardless of its size or function. “Protein” and “polypeptide” are often used in reference to relatively large polypeptides, whereas the term “peptide” is often used in reference to small polypeptides, but usage of these terms in the art overlaps. The terms “protein” and “polypeptide” are used interchangeably herein when referring to a gene product and fragments thereof. Thus, exemplary polypeptides or proteins include gene products, naturally occurring proteins, homologs, orthologs, paralogs, fragments and other equivalents, variants, fragments, and analogs of the foregoing.

As used herein, the term “nucleic acid” or “nucleic acid sequence” refers to any molecule, preferably a polymeric molecule, incorporating units of ribonucleic acid, deoxyribonucleic acid or an analog thereof. The nucleic acid can be either single-stranded or double-stranded. A single-stranded nucleic acid can be one nucleic acid strand of a denatured double-stranded DNA. Alternatively, it can be a single-stranded nucleic acid not derived from any double-stranded DNA. In one aspect, the nucleic acid can be DNA. In another aspect, the nucleic acid can be RNA. Suitable nucleic acid molecules are DNA, including genomic DNA or cDNA. Other suitable nucleic acid molecules are RNA, including mRNA.

The term “expression” refers to the cellular processes involved in producing RNA and proteins and as appropriate, secreting proteins, including where applicable, but not limited to, for example, transcription, transcript processing, translation and protein folding, modification and processing. “Expression products” include RNA transcribed from a gene, and polypeptides obtained by translation of mRNA transcribed from a gene. The term “gene” means the nucleic acid sequence which is transcribed (DNA) to RNA in vitro or in vivo when operably linked to appropriate regulatory sequences. The gene may or may not include regions preceding and following the coding region, e.g. 5′ untranslated (5′UTR) or “leader” sequences and 3′ UTR or “trailer” sequences, as well as intervening sequences (introns) between individual coding segments (exons).

As used herein, the terms “treat,” “treatment,” “treating,” or “amelioration” refer to therapeutic treatments, wherein the object is to reverse, alleviate, ameliorate, inhibit, slow down or stop the progression or severity of a condition associated with a disease or disorder, e.g. infection. The term “treating” includes reducing or alleviating at least one adverse effect or symptom of a condition, disease or disorder associated with an infection. Treatment is generally “effective” if one or more symptoms or clinical markers are reduced. Alternatively, treatment is “effective” if the progression of a disease is reduced or halted. That is, “treatment” includes not just the improvement of symptoms or markers, but also a cessation of, or at least slowing of, progress or worsening of symptoms compared to what would be expected in the absence of treatment. Beneficial or desired clinical results include, but are not limited to, alleviation of one or more symptom(s), diminishment of extent of disease, stabilized (i.e., not worsening) state of disease, delay or slowing of disease progression, amelioration or palliation of the disease state, remission (whether partial or total), and/or decreased mortality, whether detectable or undetectable. The term “treatment” of a disease also includes providing relief from the symptoms or side-effects of the disease (including palliative treatment).

As used herein, the term “pharmaceutical composition” refers to the active agent in combination with a pharmaceutically acceptable carrier e.g. a carrier commonly used in the pharmaceutical industry. The phrase “pharmaceutically acceptable” is employed herein to refer to those compounds, materials, compositions, and/or dosage forms which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problem or complication, commensurate with a reasonable benefit/risk ratio.

As used herein, the term “administering,” refers to the placement of a compound as disclosed herein into a subject by a method or route which results in at least partial delivery of the agent at a desired site. Pharmaceutical compositions comprising the compounds disclosed herein can be administered by any appropriate route which results in an effective treatment in the subject.

The term “statistically significant” or “significantly” refers to statistical significance and generally means a two standard deviation (2SD) or greater difference.

Other than in the operating examples, or where otherwise indicated, all numbers expressing quantities of ingredients or reaction conditions used herein should be understood as modified in all instances by the term “about.” The term “about” when used in connection with percentages can mean±1%.

As used herein the term “comprising” or “comprises” is used in reference to compositions, methods, and respective component(s) thereof, that are essential to the method or composition, yet open to the inclusion of unspecified elements, whether essential or not.

The term “consisting of” refers to compositions, methods, and respective components thereof as described herein, which are exclusive of any element not recited in that description of the embodiment.

As used herein the term “consisting essentially of” refers to those elements required for a given embodiment. The term permits the presence of elements that do not materially affect the basic and novel or functional characteristic(s) of that embodiment.

The singular terms “a,” “an,” and “the” include plural referents unless context clearly indicates otherwise. Similarly, the word “or” is intended to include “and” unless the context clearly indicates otherwise. Although methods and materials similar or equivalent to those described herein can be used in the practice or testing of this disclosure, suitable methods and materials are described below. The abbreviation, “e.g.” is derived from the Latin exempli gratia, and is used herein to indicate a non-limiting example. Thus, the abbreviation “e.g.” is synonymous with the term “for example.”

Definitions of common terms in cell biology and molecular biology can be found in “The Merck Manual of Diagnosis and Therapy”, 19th Edition, published by Merck Research Laboratories, 2006 (ISBN 0-911910-19-0); Robert S. Porter et al. (eds.), The Encyclopedia of Molecular Biology, published by Blackwell Science Ltd., 1994 (ISBN 0-632-02182-9); Benjamin Lewin, Genes X, published by Jones & Bartlett Publishing, 2009 (ISBN-10: 0763766321); Kendrew et al. (eds.), Molecular Biology and Biotechnology: a Comprehensive Desk Reference, published by VCH Publishers, Inc., 1995 (ISBN 1-56081-569-8) and Current Protocols in Protein Sciences 2009, Wiley Intersciences, Coligan et al., eds.

Unless otherwise stated, the present invention was performed using standard procedures, as described, for example in Sambrook et al., Molecular Cloning: A Laboratory Manual (4 ed.), Cold Spring Harbor Laboratory Press, Cold Spring Harbor, N.Y., USA (2012); Davis et al., Basic Methods in Molecular Biology, Elsevier Science Publishing, Inc., New York, USA (1995); or Methods in Enzymology: Guide to Molecular Cloning Techniques Vol. 152, S. L. Berger and A. R. Kimmel Eds., Academic Press Inc., San Diego, USA (1987); Current Protocols in Protein Science (CPPS) (John E. Coligan, et. al., ed., John Wiley and Sons, Inc.), Current Protocols in Cell Biology (CPCB) (Juan S. Bonifacino et. al. ed., John Wiley and Sons, Inc.), and Culture of Animal Cells: A Manual of Basic Technique by R. Ian Freshney, Publisher: Wiley-Liss; 5th edition (2005), Animal Cell Culture Methods (Methods in Cell Biology, Vol. 57, Jennie P. Mather and David Barnes editors, Academic Press, 1st edition, 1998) which are all incorporated by reference herein in their entireties.

Other terms are defined herein within the description of the various aspects of the invention.

All patents and other publications; including literature references, issued patents, published patent applications, and co-pending patent applications; cited throughout this application are expressly incorporated herein by reference for the purpose of describing and disclosing, for example, the methodologies described in such publications that might be used in connection with the technology described herein. These publications are provided solely for their disclosure prior to the filing date of the present application. Nothing in this regard should be construed as an admission that the inventors are not entitled to antedate such disclosure by virtue of prior invention or for any other reason. All statements as to the date or representation as to the contents of these documents is based on the information available to the applicants and does not constitute any admission as to the correctness of the dates or contents of these documents.

The description of embodiments of the disclosure is not intended to be exhaustive or to limit the disclosure to the precise form disclosed. While specific embodiments of, and examples for, the disclosure are described herein for illustrative purposes, various equivalent modifications are possible within the scope of the disclosure, as those skilled in the relevant art will recognize. For example, while method steps or functions are presented in a given order, alternative embodiments may perform functions in a different order, or functions may be performed substantially concurrently. The teachings of the disclosure provided herein can be applied to other procedures or methods as appropriate. The various embodiments described herein can be combined to provide further embodiments. Aspects of the disclosure can be modified, if necessary, to employ the compositions, functions and concepts of the above references and application to provide yet further embodiments of the disclosure. Moreover, due to biological functional equivalency considerations, some changes can be made in protein structure without affecting the biological or chemical action in kind or amount. These and other changes can be made to the disclosure in light of the detailed description. All such modifications are intended to be included within the scope of the appended claims.

Specific elements of any of the various embodiments can be combined or substituted for elements in other embodiments. Furthermore, while advantages associated with certain embodiments of the disclosure have been described in the context of these embodiments, other embodiments may also exhibit such advantages, and not all embodiments need necessarily exhibit such advantages to fall within the scope of the disclosure.

The technology described herein is further illustrated by the following examples which in no way should be construed as being further limiting.

Some embodiments of the technology described herein can be defined according to any of the following numbered paragraphs:

-   -   1. An assay comprising:         -   Measuring the level of a gene expression product of at least             one gene of Tables 4 and 5 a test sample obtained from a             subject;         -   wherein a decrease in the level of a gene expression product             of a gene of Table 4 relative to a reference level indicates             the subject has a higher risk of having or developing an             infection and an increase in the level of a gene expression             product of a gene of Table 5 relative to a reference level             indicates the subject has a higher risk of having or             developing an infection.     -   2. An assay comprising:         -   contacting a sample obtained from a subject at risk of             developing an infection with a probe to detect the level of             a gene expression product of at least one gene of Tables 4             and 5;         -   measuring the presence or intensity of a signal which             indicates the presence or level of the gene expression             product in the sample;         -   wherein a decrease in the level of a gene expression product             of a gene of Table 4 relative to a reference level indicates             the subject has a higher risk of having or developing an             infection and an increase in the level of a gene expression             product of a gene of Table 5 relative to a reference level             indicates the subject has a higher risk of having or             developing an infection     -   3. A method of identifying a subject in need of treatment for         infection, the method comprising:         -   measuring the level of a gene expression product of at least             one gene of Tables 4 and 5 in a test sample obtained from a             subject; and         -   identifying the subject as being in need of treatment for             infection when the level of a gene expression product of a             gene of Table 4 is decreased relative to a reference level             and the level of a gene expression product of a gene of             Table 5 is increased relative to a reference level.     -   4. A method of determining if a subject is at risk for         infection, the method comprising:         -   providing a sample obtained from the subject;         -   measuring the level of a gene expression product of at least             one gene of Tables 4 and 5 in the sample;         -   comparing the level of the gene expression product in the             sample to a reference level of the gene expression product;         -   determining that the subject is at risk for infection when             the level of a gene expression product of a gene of Table 4             is decreased relative to a reference level and the level of             a gene expression product of a gene of Table 5 is increased             relative to a reference level; and         -   determining that the subject is not at risk for infection             when the level of a gene expression product of a gene of             Table 4 is not decreased relative to a reference level and             the level of a gene expression product of a gene of Table 5             is not increased relative to a reference level.     -   5. A method of determining the efficacy of a treatment for         infection, the method comprising:         -   (a) measuring the level of a gene expression product of at             least one gene of Tables 4 and 5 in a test sample obtained             from a subject before administration of the treatment;         -   (b) measuring the level of the gene expression product in a             test sample obtained from a subject after administration of             the treatment; and             -   wherein the treatment is determined to be efficacious                 when the level of a gene expression product of a gene of                 Table 4 measured in step (b) is not decreased relative                 to the level measured in step (a) and the level of a                 gene expression product of a gene of Table 5 measured in                 step (b) is not increased relative to the level measured                 in step (a).     -   6. The method of paragraph 5, wherein the treatment for         infection is an anti-sepsis treatment.     -   7. A method of treatment for infection comprising;         -   measuring the level of a gene expression product of at least             one gene of Tables 4 and 5 in a test sample obtained from a             subject;         -   treating the subject with a treatment selected from the             group consisting of:             -   antibiotics; extended courses of antibiotics;                 immunotherapy; and LPS removal;         -   when the level of a gene expression product of a gene of             Table 4 is decreased relative to a reference level and the             level of a gene expression product of a gene of Table 5 is             increased relative to a reference level.     -   8. A method of treatment for infection comprising;         -   administering a treatment selected from the group consisting             of:             -   antibiotics; extended courses of antibiotics;                 immunotherapy; and LPS removal;         -   to a subject determined to have a level of a gene expression             product of a gene of Table 4 that is decreased relative to a             reference level or a level of a gene expression product of a             gene of Table 5 that is increased relative to a reference             level.     -   9. The assay or method of any of paragraphs 1-8, wherein the         level of a gene expression product is determined by measuring         the level of a nucleic acid.     -   10. The assay or method of any of paragraphs 1-9, wherein the         level of a gene expression product is determined by determined         the level of a RNA transcript.     -   11. The assay or method of any of paragraphs 1-10, wherein the         level of the nucleic acid is determined using a method selected         from the group consisting of:         -   RT-PCR; quantitative RT-PCR; Northern blot; microarray based             expression analysis;         -   next-generation sequencing; and RNA in situ hybridization.     -   12. The assay or method of any of paragraphs 1-11, wherein the         level of a gene expression product is determined by measuring         the level of a polypeptide.     -   13. The assay or method of paragraph 12, wherein the level of         the polypeptide is determined using a method selected from the         group consisting of:         -   Western blot; immunoprecipitation; enzyme-linked             immunosorbent assay (ELISA); radioimmunological assay (RIA);             sandwich assay; fluorescence in situ hybridization (FISH);             immunohistological staining; radioimmunometric assay;             immunofluoresence assay; mass spectroscopy; FACS; and             immunoelectrophoresis assay.     -   14. The assay or method of any of paragraphs 1-13, wherein the         polypeptide level is measured using immunochemistry.     -   15. The assay or method of paragraph 14, wherein the antibody         reagent is detectably labeled or generates a detectable signal.     -   16. The assay or method of any of paragraphs 1-15, wherein the         expression level is normalized relative to the expression level         of one or more reference genes or reference proteins.     -   17. The assay or method of any of paragraphs 1-16, wherein the         expression level of a gene expression product of at least two         genes of Tables 4 and 5 are measured.     -   18. The assay or method of any of paragraphs 1-17, wherein the         expression level of a gene expression product of at least three         genes of Tables 4 and 5 are measured.     -   19. The assay or method of any of paragraphs 1-18, wherein the         expression level of a gene expression product of at least four         genes of Tables 4 and 5 are measured.     -   20. The assay or method of any of paragraphs 1-19, wherein the         expression level of a gene expression product of at least five         genes of Tables 4 and 5 are measured.     -   21. The assay or method of any of paragraphs 1-20, wherein the         expression level of a gene expression product of at least six         genes of Tables 4 and 5 are measured.     -   22. The assay or method of any of paragraphs 1-21, wherein the         genes are selected from the group consisting of:         -   THBS1; ARHGEF7; MDFIC; CCND2; OSBPL8; DCAF7; TMEM50B;             GOLGA8A and/or GOLGA8B; SMARCA4; WHSC1L1; LOC101928343; and             LINC00869.     -   23. The assay or method of any of paragraphs 1-22, wherein the         expression level of a gene expression product of THBS1; ARHGEF7;         MDFIC; CCND2; OSBPL8; DCAF7; TMEM50B; GOLGA8A and/or GOLGA8B;         SMARCA4; WHSC1L1; LOC101928343; and LINC00869 is measured.     -   24. The assay or method of any of paragraphs 1-23, wherein the         expression level of a gene expression product of CCND2; THBS1;         MDFIC; SMARCA4; WHSC1L1; TMEM50B; DCAF7; and OSBPL8 is measured.     -   25. The assay or method of paragraph 24, wherein the subject is         at least 16 years of age or older.     -   26. The assay or method of any of paragraphs 1-25, wherein the         expression level of a gene expression product of NFKB2; MAX;         PDLIM5; GATAD2B; and ZSCAN30 is measured.     -   27. The assay or method of paragraph 26, wherein the subject is         15 years of age or younger.     -   28. The assay or method of any of paragraphs 1-27, wherein the         sample comprises blood or plasma.     -   29. The assay or method of any of paragraphs 1-28, wherein the         sample comprises muscle tissue and the one or more genes are         selected from the group consisting of:         -   ALDH1A1; ALDH1A2; ALDH3B1; ALDH5A1; ALDH6A1; and ALDH7A1.     -   30. The assay or method of any of paragraphs 1-29, wherein the         method further comprises determining the values of total body         surface area (TBSA) burns, age, and/or inhalation status;         -   wherein an increase in any of the preceding values indicates             an increased risk of the subject having or developing             infection.     -   31. The assay or method of any of paragraphs 1-30, wherein the         method further comprises multiplying each gene expression value         measured, and optionally, the total body surface area (TBSA)         burns, age, and/or inhalation status values, by a coefficient         and adding the resulting products to yield a risk value.     -   32. The assay or method of paragraph 1-32, wherein a risk value         of greater than the computed reference baseline coefficient         value indicates the subject is at risk of having or developing         infection and/or is in need of treatment for infection.     -   33. The assay or method of paragraph 1-32, wherein the         coefficient is about the coefficient provided in Table 7.     -   34. The assay or method of paragraph 33, wherein a risk value of         greater than about −1.1912 indicates the subject is at risk of         having or developing infection and/or is in need of treatment         for infection.     -   35. The assay or method of any of paragraphs 1-34, wherein the         infection comprises a microbe selected from the group consisting         of:         -   Gram-negative bacteria; Staphylococcus spp.; Staphylococcus             aureus; coagulase-negative Staphylococci; Enterococcus spp.;             Candida spp. Escherichia coli; Enterobacter spp.; Klebsiella             pneumonia; Acinetobacter spp.; Pseudomonas aeruginosa;             Streptococcus pneumonia; Streptococcus viridans;             Gram-positive bacteria; Serratia marcescens; Hemophilus             influenza; Stenotrophomonas spp.; Proteus; Aspergillus;             Neisseria; Clostridium sp.; Bacteroides sp; fungi;             cytomegalovirus; and herpes virii.     -   36. The assay or method of any of paragraphs 1-35, wherein the         subject at risk of infection is a subject at risk of a condition         selected from the group consisting of:         -   multiple infection episodes; sepsis; pneumonia; urinary             tract infection; blood stream infection; catheter-related             infection; and wound infection.     -   37. The assay or method of any of paragraphs 1-36, wherein the         subject at risk of infection is a subject having or diagnosed as         having a condition selected from the group consisting of:         -   a burn injury; inhalation injury; immunosuppression; major             surgical procedures; intubation or catheters; blunt trauma;             penetrating trauma; burn trauma; diabetes; diabetic             infection complications; HIV; or         -   a subject in the intensive care unit and with central lines.     -   38. The assay or method of any of paragraphs 1-37, further         comprising the step of detecting the presence of         susceptibility-associated SNPs or pathogen markers in the sample         obtained from the subject.     -   39. A kit for performing the method/assay of any of paragraphs         1-38.     -   40. A computer system for determining the risk of a subject         having or developing an infection, the system comprising:         -   a measuring module configured to measure the level of a gene             expression product of at least one gene of Tables 4 and 5 in             a test sample obtained from a subject;         -   a storage module configured to store output data from the             determination module;         -   a comparison module adapted to compare the data stored on             the storage module with a reference level, and to provide a             retrieved content, and         -   a display module for displaying whether the sample comprises             a level of the gene expression product which is             significantly different relative to the reference expression             level and/or displaying the relative level of the gene             expression product.     -   41. The system of paragraph 40, further comprising an output         module for reporting/displaying the probability of a subject         developing infections.     -   42. The system of paragraph 41, wherein the probablility is         calculated from the input from the measuring module and clinical         parameters.     -   43. The system of any of paragraphs 41-42, wherein the         probability is calculated with at least a 95% confidence         interval.     -   44. The system of any of paragraphs 41-43, wherein the measuring         module measures the intensity of a detectable signal from an         assay indicating the level of a polypeptide in the test sample.     -   45. The system of paragraph 44, wherein the assay is an         immunoassay.     -   46. The system of any of paragraphs 40-45, wherein the measuring         module measures the intensity of a detectable signal from a         RT-PCR assay indicating the level of a RNA transcript in the         test sample.     -   47. The system of any of paragraphs 40-46, wherein if the         computing module determines that the level of the gene         expression product in the test sample obtained from a subject         differs by a statistically significant amount from the reference         level, the display module displays a signal indicating that the         levels in the sample obtained from a subject are different than         those of the reference level.     -   48. The system of any of paragraphs 40-47, wherein the signal         indicates that the subject has an increased likelihood of having         or developing an infection.     -   49. The system of any of paragraphs 40-48, wherein the signal         indicates the subject is in need of treatment for an infection.     -   50. The system of any of paragraphs 40-49, wherein the signal         indicates the degree to which the level of the gene expression         product in the sample obtained from a subject varies from the         reference level.

EXAMPLES Example 1

Described herein are methods and assays relating to the treatment of infection. Described herein are three predictive models using multivariate logistic regression and the following covariates: 1) clinical characteristics of age, TBSA, and the presence of inhalation injury; 2) 14 genomic probe sets from early (<180 h) blood transcriptome; 3) both clinical and genomic covariates. The clinical model (AUROC=0.864 [CI, 0.794-0.933]) and the 14-probe set genomic model (AUROC=0.946 [CI, 0.906-0.986]) were highly predictive of MIE status, with the latter providing a more accurate prognosis. Combining the two increased the AUROC to 0.967 (CI, 0.940-0.993). Described herein are genomic signatures that predict hypersusceptibility to infection.

Example 2: Prediction of Multiple Infections after Severe Burn Trauma: A Prospective Cohort Study

To develop predictive models for early triage of burn patients based on hyper-susceptibility to repeated infections. Infection remains a major cause of mortality and morbidity after severe trauma, demanding new strategies to combat infections. Models for infection prediction are lacking. Secondary analysis of 459 burn patients (≥16 years old) with ≥20% total body surface area burns recruited from six US burn centers. Blood transcriptomes with a 180-h cut-off on the injury-to-transcriptome interval of 47 patients (≤1 infection episode) were compared to those of 66 hyper-susceptible patients (multiple [≥2] infection episodes [MIE]). Described herein the use of LASSO regression to select biomarkers and multivariate logistic regression to built models, accuracy of which were assessed by area under receiver operating characteristic curve (AUROC) and cross-validation.

Three predictive models were developed covariates of: (1) clinical characteristics; (2) expression profiles of 14 genomic probes; (3) combining (1) and (2). The genomic and clinical models were highly predictive of MIE status (AUROC_(Genomic)=0.946 [95% CI, 0.906-0.986]); AUROC_(Clinical)0.864 [CI, 0.794-0.933]; AUROC_(Genomic)/AUROC_(Clinical) P=0.044). Combined model has an increased AUROC_(Combined) of 0.967 (CI, 0.940-0.993) compared to the individual models (AUROC_(Combined)/AUROC_(Clinical)P=0.0069). Hyper-susceptible patients show early alterations in immune-related signaling pathways, epigenetic modulation and chromatin remodeling.

Early triage of burn patients more susceptible to infections can be made using clinical characteristics and/or genomic signatures.

Early genomic signature and clinical characteristics of 113 burn patients were used paradigmatically to build three novel predictive models of multiple, repeated infections in burn trauma, which can facilitate early triage of traumatically injured burn patients to prevent or treat sepsis. Genomic signature indicates new mechanistic aspects of hyper-susceptibility to infections.

Introduction

Although several studies have found association between specific risk factors or clinical characteristics with mortality after trauma,¹⁻⁴ studies attempting to apply those clinical characteristics or genomic biomarkers to appreciate susceptibility to infection and build predictive models are currently lacking. Improvements in early care and trauma centers have reduced early mortality considerably.^(3,5) However, severe trauma, such as burn trauma, cause immunosuppression which predispose patients to infections. Despite all medical improvements, infections remain a major cause of critical injury-related morbidity and mortality, and recurrent sepsis predisposes patients to multiple organ failure, lengthens hospital stays, and increases costs.⁶ Therefore, improvements in prevention and treatment of infections are increasingly important.^(7,8) Moreover, the rapid emergence of multi-(MDR) or pan-drug resistant (PDR) pathogens that cause highly problematic acute, persistent or relapsing infections pose a dire threat to healthcare, especially among trauma and surgical patients.^(9,10) The increased use of antibiotics has further accelerated their emergence,¹¹⁻¹³ and also increased the challenge of treating polymicrobial wound infections.^(14,15) Due to the paucity of novel anti-infectives in development, further improvement in patient care and treatment efficacy may rely heavily on optimizing existing strategies and promoting patients-tailored therapies.¹⁶⁻¹⁸

Successful personalized approach requires rigorous triaging: early and accurate identification of patients more susceptible to infections could help tailor the anti-infective treatments,^(19,20) and especially to elaborate long-term treatment plan. Future successful clinical trials aiming to improve sepsis outcome may also rely on biomarkers to identify the right patients for the right treatment.^(21,22) Several studies have reported risk factors associated with increased probability of infection and sepsis in trauma patients,²³⁻²⁶ but no specific predictive model has been developed. Existing plasma biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT) are mainly used to diagnose sepsis^(27,28) rather than reflective of susceptibility or health status. The clinical characteristics measurable rapidly upon admission are the current gold standard for prognosis of general patient's outcome.

As trauma promotes susceptibility to infection and genomic signatures appear to play an increasingly promising role in prognosis,^(26,29) the blood transcriptome and clinical characteristics data of 113 patients from the 573 thermally injured patients enrolled in the Inflammation and the Host Response to Injury study were analyzed. Using clinical characteristics available upon admission and early genomic signatures, novel predictive models were developed, as described herein, that permit early identification of burn patients at high risk of developing repeated infection indicative of an early hyper-susceptible state. The genomic signature indicates new mechanistic aspects for susceptibility to infection after burn trauma.

Methods

Subject Recruitment and Sample Selection.

This study was conducted via secondary use of the clinical and genomic data of the Inflammation and the Host Response to Injury Study (“Glue Grant”). Briefly, 573 burn patients with minimum 20% total burn surface area (TBSA) were enrolled from six institutions between 2003 and 2009 in a prospective, longitudinal study. RNA of leucocytes isolated from whole blood samples were extracted for transcriptome analysis using Affymetrix GeneChip Human Genome U133 Plus 2.0 microarrays at University of Florida—Gainesville, as described previously.³⁰ The complete inclusion/exclusion criteria are described elsewhere.³¹ Permission for this secondary use of the de-identified data was obtained from the Massachusetts General Hospital Institutional Review Board.

The patient inclusion process is summarized in FIG. 1. From 573 potential patients in the data pool, patients were selected that were at least 16 years old with early transcriptome data. A 180-h cut-off limit was set on the injury-to-transcriptome interval to include only samples that were obtained early relative to the recovery process, while still allowing enough samples to remain eligible for biomarker discovery. If multiple blood samples were collected from a patient, only the earliest eligible sample was included. Patients who died within 9 days of blood collection and had fewer than two infection episodes during this time window were excluded (FIG. 1). The method for collection of data related to clinical characteristics is described elsewhere.³¹ To enable direct comparisons, as well as combination of clinical and genomic prediction, the same set of patients was used for both clinical characteristic and genomic signature prediction models.

Definition of Outcomes.

Infections were defined according to the information collected in the Glue Grant database based on previously described standards.³² Infection episodes were quantified for each patient for up to 60 days after blood sample collection. A decision tree (FIG. 1 and FIG. 11) was developed for evaluating each record based on: (1) time of infection; (2) type of infection; and (3) the pathogen(s) isolated. Since no genotyping data of the isolated pathogen species were available, it was not possible to classify whether a later episode was caused by the same strain isolated earlier. However, once a record was counted, the infection type and isolated pathogen combination (e.g. Pseudomonas aeruginosa+lung) was put on a “waiting list” for the next 6 days, which likely reduced the likelihood of an infection episode caused by the same isolate from being counted. Subsequent records that were part of the same infection episode were thereby omitted. The patients were separated into two groups based on susceptibility to infection, measured by the number of independent infection episodes recorded. Patients with ≤1 infection episodes were defined as the less susceptible control group (N=47), and patients with ≥2 (multiple) infection episodes (MIE) as the hyper-susceptible case group (N=66).

Microarray Processing and Filtering

Raw microarray data (.CEL files) were downloaded from the Glue Grant website (available on the world wide web at.gluegrant.org/trdb/) and filtered using the steps outlined in FIG. 1; FIG. 11; FIG. 9B. The gcrma³³ package on the R/Bioconductor platform³⁴ was used to normalize 124 blood samples from 124 eligible patients collected within 180 h post-injury. Samples identified as outliers by arrayQualityMetrics³⁵ were excluded from subsequent analysis. One patient was removed due to incompleteness of clinical data. Two patients' datasets were discarded due to mortality within 9 days after sample collection. After these filtration steps, 113 blood samples were deemed suitable high-quality microarray data sets for subsequent functional analyses, biomarker discovery, and modeling.

The EMA package³⁶ in R software was used to filter outlying or information-poor probe sets. Probe sets with a maximum log₂ expression value below 3.5, were eliminated, reducing the number of probe sets from 54,675 to 26,107. Using limma package,³⁷ 1142 probe sets with an at least 1.5-fold difference between less susceptible patients and hyper-susceptible patients and with an average expression level of at least 3 were selected for functional analyses and biomarker panel selection process.

Statistical Analysis Clinical Data Set.

Continuous variables are reported as means (standard deviations), or as medians with inter-quartile ranges (IQRs) as indicated. Categorical variables are reported as frequencies and percentages. Demographic variables between less susceptible and hyper-susceptible patients were tested for statistical difference with a Wilcoxon rank sums test, a Chi-square test, or a Fisher's exact test as appropriate. Statistical significance was accepted at P<0.05 (two-tailed when appropriate).

Body mass index (BMI) was calculated as weight/height² (kg/m²). For patients ≥20 years old, BMI categories of underweight, healthy, overweight and obese were define according to BMI numbers: <18.5, 18.5-24.9, 25-29.9, and ≥30, respectively; whereas for patients <20 years old, the same BMI categories were defined using percentile ranking based on Centers for Disease Control and Prevention BMI-for-age growth charts: <5^(th) percentile, 5^(th) to <85^(th) percentile, 85^(th) to <95^(th) percentile, and ≥95^(th) percentile, respectively.

Genomic Data Set.

In the evaluation of significant expression differences between less susceptible and hyper-susceptible patients, Benjamini-Hochberg multiple-comparison adjustments were applied to control for false discovery rate.

Development of the Clinical Predictive Models.

Stepwise logistic regression was implemented with an entry level of 0.3 and a stay level of 0.25 to identify significant predictor variables among clinical covariates relevant to the outcome variable of MIE: TBSA, age, BMI, and the presence of inhalation injury. Predictive power was determined by calculating area under receiver operating characteristic curve (AUROC), reported with 95% confidence intervals (CIs).

Development of the Genomic Predictive Models.

The LASSO regularized regression method³⁸ implemented in the glmnet package³⁹ in R software was used to identify probe sets that collectively predicted the likelihood of MIE. 10-fold cross-validation (CV) was used to select the optimal value of LASSO penalty weighting, λ. The value of λ that gave the minimum average binomial deviance plus 1 standard error on the test set, λ_(1se), was used to select probe sets (FIG. 3A). λ_(1se) is a stronger penalty parameter to guard against over-fitting than which minimizes the average binomial deviance of CV (FIG. 3B). This 10-fold CV process was repeated 100 times to generate 100λ_(1se) values. The median λ_(1se), 0.0940, yielded selection of a 14-probe-set biomarker panel (Table 2). Logistic regression was performed to model the MIE outcome with the log 2 expression values of the 14 probe sets as explanatory variables. Furthermore, we conducted multivariate logistic regression with the clinical covariates TBSA, age, and inhalation injury together with the 14 probe sets for the outcome variable of MIE. Leave-one-out cross-validation was used to assess the degree of over-fitting and model performance.

Functional Analysis

Functional and pathway analyses were conducted using Ingenuity IPA (Ingenuity® Systems) and DAVID.⁴⁰

Software Platform and Package Versions

R (version 2.15.*); EMA package for R (version 1.3.2); pROC package for R (version 1.5.4); limma package for R (version 3.14.4); glmnet package for R (version 1.9-3); arrayQualityMetrics package for R (version 3.14.0); gcrma package for R (version 2.30.0); JMP Pro 10 and SAS 9.3 (SAS Institute Inc., North Carolina, USA).

Results

Clinical Characteristics.

From a pool of 573 patients, 124 met the inclusion criteria, of which 11 were unsuitable for modeling, leaving a cohort of 113 patients (FIG. 1), including 47 patients less susceptible to infection (control group with ≤1 infection episodes) and 66 hyper-susceptible patients (case group with multiple [≥2] infection episodes [MIE]). The demographics, injury characteristics, and outcomes of these 113 patients are summarized in Table 1.

From 612 microbiological records for the 113 patients in the final cohort, 325 independent infection episodes, 107 (32.9%) of which are polymicrobial at the species level, were identified. Twenty-four patients had no infection episodes, 23 had one episode, and 66 had MIE. The less susceptible and hyper-susceptible patients show significantly different clinical characteristics (Table 1). Relative to the control group, hyper-susceptible patients were slightly older (mean, 38.2, SD 16.4 vs 37.0, SD 14.6), had higher TBSA (46%, IQR 35-71 vs 32%, IQR 23-41, P<0.0001), had more inhalation injuries (41/66 [62.1%] vs 8/47 [17.0%], P<0.0001) and were more severely ill (according to their APACHE II score 24, IQR 18-29 vs 13, IQR 9-20, P<0.0001). They also had longer hospital stays (median, 60, IQR 33-71 vs 20, IQR 15-30, P<0.0001), more days on mechanical ventilation (median, 28, IQR13-40 vs 2, IQR 0-5, P<0.0001), and had a higher mortality (18/66 [27.3%] vs 3/47 [6.4%], P=0.0029) (Table 1). The median post-injury interval for the second episode in the case group was 15 days (IQR, 10-20; range, 3-43), a time window that provides opportunity for prophylactic intervention.

Inhalation injury significantly increased the risk of developing MIE and may be related to pneumonia risk in particular: 78.8% of hyper-susceptible patients had pneumonia vs 10.6% of controls; among cases, 84.7% had both MIE and inhalation injuries, 67.4% had both pneumonia and inhalation injuries. Interestingly, 4/5 of underweight patients had MIE (Table 1), supporting the notion that being overweight and mild obesity may be protective against post-injury infection whereas being underweight increases risk.^(32,41)

Burn wound infection and nosocomial pneumonia were the most frequent types of infection observed (Table 1; FIG. 2A). Pseudomonas aeruginosa and Staphylococci (both Staphylococcus aureus and coagulase negative Staphylococci) were the most commonly isolated micro-organisms (Table 1; FIG. 2B). P. aeruginosa and Acinetobacter infections were more common among patients with MIE than controls, suggesting that hyper-susceptible patients were even more susceptible to nosocomial Gram-negative pathogens.

MIE Prediction from Clinical Characteristics

Stepwise logistic regression to select covariates for modeling from TBSA, age, BMI, and the presence of inhalation injury. The final multivariate logistic regression model included three covariates: TBSA, age, and inhalation injury, which were significant independent predictors of MIE. The AUROC, CV AUROC, sensitivity, and specificity values for the clinical characteristics model are 0.845 (95% CI, 0.773-0.916), 0.838 (95% CI, 0.762-0.914), 0.803 (95% CI, 0.683-0.887), and 0.745 (95% CI, 0.594-0.856), respectively (FIG. 4). The model's positive and negative predictive values were 0.815 (95% CI, 0.696-0.843) and 0.729 (95% CI, 0.579-0.843), respectively. Inhalation injury significantly increased MIE incidence (odds ratio [OR], 6.942; 95% CI, 2.482-19.417). Patients who had inhalation injuries were twice as likely to get pneumonia compared to those without them (risk ratio [RR], 2.05; 95% CI, 1.37-3.07). Among those who had inhalation injuries, 67.4% had pneumonia, and 83.67% had MIE. TBSA (OR, 1.078; 95% CI, 1.040-1.118) and age (OR, 1.040; 95% CI, 1.006-1.075) were also associated with increased infection susceptibility.

MIE Prediction from Genomic Biomarkers in Blood

Ten-fold CV using LASSO regularized regression³⁸ of the 1142 probe sets that presented a minimum of 1.5-fold change between the two patient groups yielded a minimal set of 14 predictors (probe sets) that together optimized the fit of the model (FIGS. 3A and 3B). Of these 14 probe sets—which mapped to 12 genes—4 were upregulated and 10 were down-regulated (Table 2, all P<0.01; heat map and clustering of patients and biomarkers not shown; see FIG. 2A-2B for expression profiles of each probe set). The biological processes associated with each probe set are presented in Table 3 together with the coefficients of the biomarker panel logistic regression model (model intercept=0.7449; Stable 12).

The AUROC, CV AUROC, sensitivity, and specificity values for the resulting genomic signature model are 0.946 (95% CI, 0.906-0.986), 0.872 (95% CI, 0.804-0.940), 0.924 (95% CI, 0.825-0.972), and 0.830 (95% CI, 0.687-0.919), respectively (FIG. 4), confirming the model to be highly sensitive and specific. The positive and negative predictive values of the model were 0.884 (95% CI, 0.779-0.945) and 0.886 (95% CI, 0.746-0.957), respectively. Each patient's probability of developing MIE estimated from the clinical or genomic biomarker logistic regression models was compared with each of the observed outcomes, using cut-off points of 30% to 70% as being uncertain. It was found that the clinical model correctly predicted outcomes of 73 (65%) patients with certainty. Comparatively, the genomic biomarker model correctly predicted 90 (80%) patients with certainty, showing a 15% improvement over the clinical model. Both models misclassified 9 patients (8%). Collectively, these data indicate that genomic biomarkers may complement triage by clinical characteristics and enhance early prediction of a patient's likelihood to develop MIE.

MIE Prediction from a Combined Model

A multivariate logistic model that included the aforementioned clinical covariates (TBSA, age, presence of inhalation injury) and genomic biomarkers resulted in an AUROC (0.967; 95% CI, 0.940-0.993) that was significantly greater than that for the clinical model (P=0.0069), but not significantly different from that of the genomic biomarker panel model (FIG. 4). The positive and negative predictive values of the combined model were 0.881 (95% CI, 0.773-0.943) and 0.848 (95% CI, 0.705-0.932), respectively. The estimates of the above models are listed in Table 12.

Functional and Canonical Pathway Changes in Patients with MIE Revealed by Transcriptome Data Analysis

The 1142 probe sets showing a minimum of 1.5-fold change in hyper-susceptible patients versus less susceptible patients were mapped to 844 annotated genes. Functionally related genes were identified among these 884 genes using Gene Ontology (GO). Subsequent analysis of the changes in canonical pathways and functions linked to these 844 genes indicated that hyper-susceptible patients' transcriptomes demonstrated the following early functional changes relative to control transcriptomes: (1) early activation of immune cells, increased chemotaxis and trafficking; (2) decreased expansion of leukocytes, thymocytes, and number of phagocytes, and increased cell death and apoptosis; and (3) suppression of immune cell activation and lymphoid organ development (Table 2). The 1142 probe sets showed enrichment in four main gene ontology biological process categories: (1) immune response; (2) epigenetic modulation of gene expression; (3) transcription; and (4) metabolism (Table 13). Functional enrichment clustering is also in agreement with the enrichment of the 4 functional groups (Table 14). The top 30 affected pathways were mainly involved in immune cell signaling and cytokine signaling (FIG. 5). Canonical pathway analysis using IPA software (FIG. 5) largely agrees with KEGG pathway enrichment analysis using DAVID (Table 15), providing additional confidence. Overall, many of the predicted functional changes (Table 2) are downstream of the affected canonical pathways (FIG. 5; Table 15).

Canonical Pathways and T-Cell Signaling

Significant changes in IL-8 signaling (17 upregulated and 12 down-regulated genes [17 up/12 down]), Gaq signaling (16 up/9 down), Rho family GTPase signaling (20 up/10 down) and integrin signaling (21 up/9 down) indicates that the adhesion and migration of leukocytes are affected (Table 2; Table 14; and FIG. 5). The changes in chemotaxis may be partially caused by the presence of bacteria at wound site, as fMLP signaling pathway (12 up/8 down) suggests. Genes involved in phospholipase C signaling, a regulator of chemotactic response are differentially expressed (20 up/16 down). The increased cell movement, adhesion, and chemotaxis are related to phagocytosis process (e.g. FcγR-mediated phagocytosis, Table 12), clearance of the pathogen from the site of infection, and induced by host damage associated molecular patterns (DAMP).

Strong evidence was found that T-cells were also differentially regulated in case patients. Several pathways, including T-cell receptors (TCR) (7 up/16 down), JAK-STAT signaling (9 up/7 down), PKCθsignaling (8 up/15 down), and IL-6 signaling pathway (13 up/6 down) are known to regulate T-cell differentiation, activation, and cytokine production. Changes in iCOS-iCOSL signaling (10 up/14 down), CD28 signaling (11 up/16 down), and IL-2 signaling (7 up/7 down), indicate that T helper cell maturation and proliferation were likely affected. In summary, patient transcriptome data is consistent with compromised cellular immune responses mediated by impaired T-cells signaling.

Functional Enrichment in Histone Modification and Chromatin Remodeling

Evidence was found for dramatic epigenetic changes in leukocytes that long precede patient outcome of MIE. Functions related to epigenetic modulation were commonly enriched in our functional enrichment analyses (Tables 13, 14, and 11). Notably, 42 probe sets (39 genes) have functional annotation associated with chromatin remodeling and histone modifications (Table 11). Two genes from the biomarker panel involved in epigenetic modulation were found to be down-regulated in the case group with MIE: WHSC1L1, which encodes a histone lysine methyltransferase; and SMARCA4, which encodes an ATP-dependent helicase related to the SWI/SNF chromatin remodeling factor. A multitude of differentially expressed genes encoding histone post-translational modifiers as well as key components of the nucleosome remodeling complex mediating ATP-dependent nucleosome sliding, including SMARCC1, SMARCA4, CHD2 and CHD9, were down-regulated (Table 11). Other notable histone methyltransferases/demethylases differentially expressed include KDM4, KDM5C, KDM6, PRDM5, SETD2, SETDB2, and SUZ12. Genes coding for histone deacetylases/acetyltransferases and associated factors including HDAC9, KAT6A and EP400 were down-regulated and histone acetylation recognizing bromodomain containing protein, BRD2, was upregulated in the case group. Furthermore, critical non-histone heterochromatin proteins HP1-α and -γ were down-regulated, as well as core histone cluster. Taken together, our data may suggest a global loss of heterochromatin and genome instability, as well as probable gene-specific transcriptional deregulation in hyper-susceptible patients compared to controls.

Discussion

The work presented reports novel predictive models for hyper-susceptibility to infection among, e.g., traumatically injured patients, using genomic biomarkers and/or clinical characteristics that have not been used to build statistical prognostic models for the purpose of predicting infection outcomes. Evidence is provided that these models can identify burn patients at high risk of developing repeated infections indicative of their hyper-susceptible state. To our knowledge, this work is the first to describe such models in trauma patients, and the first to describe functional transcriptome data of burn patients in relation to infections. The prediction accuracy of hyper-susceptibility to MIE is significantly increased over clinical markers when the genomic signature is used, providing strong evidence of the promising role of genomic biomarkers in prognosis even when used alone. By combining the biomarker panel with clinical characteristics, even better prediction accuracy is provided, supporting the applicability of using genomic signature to increase confidence in data used for treatment decision-making.

Clinical Implications.

Two distinct patient groups with different genomic signatures and clinical characteristics were identified, essentially allowing the rapid identification of patients with a high risk of developing MIE following burn trauma. Although burn patients generally suffer from immunosuppression, clinical experience and the present data suggest that the severity of immunosuppression and infection outcome vary. These data suggest that patients can receive personalized therapy depending on their susceptibility to infection, e.g., triaged by physical exam and a blood test on admission. This information can facilitate the determination of appropriate treatment courses, particularly in regards to antibiotic use, allowing for selective use of prophylactic antibiotics and more objective justification of length of treatment courses. For the patient, this can limit complications related to unneeded antibiotics, reduce the burden of lines needed to deliver the antibiotics, and streamline hospital care. For the population, this can promote antibiotic stewardship, help stem the emergence of resistant organisms, and reduce the cost of care.

Mechanistic Aspects.

Genomic signatures provide insight into the molecular mechanisms of the more susceptible health status, and may aid in the discovery of novel therapeutic targets. The present findings point to novel potential targets for the prevention and/or early treatment of infections. Functional analyses of the 1142 biomarker candidates suggest new aspects into the pathophysiology of susceptibility to MIE after trauma. Susceptibility to MIE was associated with early alterations in numerous signaling pathways related to innate and adaptive immune responses, and changes in epigenetic modulation and metabolism.

Presented herein is evidence for increased chemotaxis, cell adhesion, and migration of immune cells, and simultaneously, decreased expansion of immune cells and development of lymphatic system components. Without wishing to be bound by theory, this seeming contradiction may well be the consequences of dysfunctional immune system and cytokine signaling, especially in T-cells.

The present data indicate that epigenetic changes occur early on, rather than mainly as a consequence of septic shock. Epigenetic regulation of immune system is a common mechanism for gene expression regulation and it plays a role in long-term immunosuppression after sepsis.⁴⁶ Tightly regulated chromatin remodeling is required for transcriptional regulation, which is vital for proper host immune and inflammatory responses.⁴⁷ Among the genes associated with epigenetic regulations, several have confirmed roles in immune responses, such as KAT6A and KDM6B (Table 11).^(46,48-50) Furthermore, the data further supports the notion that genes related to cell-cycle control and DNA repair have roles in both immune responses and tumorigenesis. Without wishing to be bound by theory, the dramatic epigenetic changes could potentially explain the biomarker panel could predict MIE that occurred weeks later, and the underlying mechanisms that favor infections by Gram-negative opportunistic pathogens.

appropriate biomarkers and additional information regarding patient health status might be essential for successful clinical trials of anti-sepsis drugs.^(21,22) Identification of the hyper-susceptible patients could enable more focused study design when expensive/invasive interventions, such as for the testing of cutting-edge technologies or products are involved by directing intervention to those who need it most. Identification of this group early after admission could also allow adjunctive treatments such as immunotherapy, extra-corporeal lipopolysaccharide removal, and other novel treatments to be tested prior to the decline of the patient's clinical status due to MIE.

In some embodiments, described herein is a comprehensive diagnostic tool set will depend on the integration of genomic signatures of both host and pathogen. The blood biomarkers reported could be integrated with other diagnostic tools, such as genomic single nucleotide polymorphisms (SNPs) that predispose certain patients to infection,^(51,52). Physician decisions rely heavily on blood tests over the course of recovery, and a positive culture is still the most accepted and reliable method for diagnosing infection. Using biomarkers, these blood samples could also allow monitoring of the changes in susceptibility status and adjustment of treatments accordingly. Modern molecular based microbiological tests,⁵³ such as detection of P. aeruginosa in wound biopsy using RT-PCR based assays,⁵⁴ have been developed. Several molecular early detection kits have become commercially available for diagnosing common bloodstream infections, and have been found to show some promise despite of much room left for improvement.^(55,56) The presently described biomarkers on the host response can work synergistically with these tests to support physician decisions.

The definition of hyper-susceptibility is based on natural definition of having repeated infections. Changing this definition, for example, to having at least three infection episodes, did not significantly change the biomarkers identified (data not shown).

Although this work and focused on thermally injured trauma patients, the approach is applicable to other types of trauma and surgical patients.

REFERENCES

-   1. Morris J A, MacKenzie E J, Damiano A M, et al. Mortality in     trauma patients: the interaction between host factors and severity.     J Trauma. 1990; 30:1476-1482. -   2. Kraft R, Herndon D N, Al-Mousawi A M, et al. Burn size and     survival probability in paediatric patients in modern burn care: a     prospective observational cohort study. Lancet. 2012; 379:1013-1021. -   3. Ryan C M, Schoenfeld D A, Thorpe W P, et al. Objective estimates     of the probability of death from burn injuries. The New England     journal of medicine. 1998; 338:362-366. -   4. Osler T, Glance L, Buzas J S, et al. A trauma mortality     prediction model based on the anatomic injury scale. Ann Surg. 2008;     247:1041-8. -   5. MacKenzie E J, Rivara F P, Jurkovich G J, et al. A National     Evaluation of the Effect of Trauma-Center Care on Mortality. N Engl     J Med. 2006; 354:366-378. -   6. Church D, Elsayed S, Reid O, et al. Burn wound infections. Clin     Microbiol Rev. 2006; 19:403-434. -   7. Bloemsma G C, Dokter J, Boxma H, et al. Mortality and causes of     death in a burn centre. Burns. 2008; 34:1103-1107. -   8. Ingraham A M, Xiong W, Hemmila M R, et al. The attributable     mortality and length of stay of trauma-related complications: a     matched cohort study. Ann Surg. 2010; 252:358-62. -   9. Kesarwani M, Hazan R, He J, et al. A quorum sensing regulated     small volatile molecule reduces acute virulence and promotes chronic     infection phenotypes. PLoS pathogens. 2011; 7:e1002192. -   10. Bandyopadhaya A, Kesarwani M, Que Y-A, et al. The quorum sensing     volatile molecule 2-amino acetophenon modulates host immune     responses in a manner that promotes life with unwanted guests. PLoS     pathogens. 2012; 8:e1003024. -   11. Boucher H W, Talbot G H, Bradley J S, et al. Bad bugs, no drugs:     no ESKAPE! An update from the Infectious Diseases Society of     America. Clin Infect Dis. 2009; 48:1-12. -   12. Avni T, Levcovich A, Ad-El D D, et al. Prophylactic antibiotics     for burns patients: systematic review and meta-analysis. BMJ     (Clinical research ed.). 2010; 340:c241. -   13. Cohen N R, Lobritz M A, and Collins J J. Microbial Persistence     and the Road to Drug Resistance. Cell Host &amp; Microbe. 2013;     13:632-642. -   14. Pirnay J-P, De Vos D, Cochez C, et al. Molecular Epidemiology of     Pseudomonas aeruginosa Colonization in a Burn Unit: Persistence of a     Multidrug-Resistant Clone and a Silver Sulfadiazine-Resistant Clone.     Journal of Clinical Microbiology. 2003; 41:1192-1202. -   15. De Vos D, Lim A Jr, Pirnay P, et al. Analysis of epidemic     Pseudomonas aeruginosa isolates by isoelectric focusing of     pyoverdine and RAPD-PCR: modern tools for an integrated     anti-nosocomial infection strategy in burn wound centres [Internet].     Burns. 1997; 23:379-386. -   16. Brunkhorst F M, Oppert M, Marx G, et al. Effect of empirical     treatment with moxifloxacin and meropenem vs meropenem on     sepsis-related organ dysfunction in patients with severe sepsis: a     randomized trial. JAMA: the journal of the American Medical     Association. 2012; 307:2390-2399. -   17. Schuetz P, Litke A, Albrich W C, et al. Blood biomarkers for     personalized treatment and patient management decisions in     community-acquired pneumonia. Curr Opin Infect Dis. 2013; 26:159-67. -   18. Härtel C, Deuster M, Lehrnbecher T, et al. Current approaches     for risk stratification of infectious complications in pediatric     oncology. Pediatr Blood Cancer. 2007; 49:767-73. -   19. Angus D C. The search for effective therapy for sepsis: back to     the drawing board? JAMA: the journal of the American Medical     Association. 2011; 306:2614-2615. -   20. Kuehn B M. Guideline Promotes Early, Aggressive Sepsis Treatment     to Boost Survival. JAMA. 2013; 309:969-970. -   21. Schuetz P, Haubitz S, and Mueller B. Do sepsis biomarkers in the     emergency room allow transition from bundled sepsis care to     personalized patient care? Curr Opin Crit Care. 2012; 18:341-9. -   22. Angus D C, and van der Poll T. Severe sepsis and septic shock.     The New England journal of medicine. 2013; 369:840-851. -   23. Nichols R L, Smith J W, Klein D B, et al. Risk of infection     after penetrating abdominal trauma. The New England journal of     medicine. 1984; 311:1065-1070. -   24. Kisat M, Villegas C V, Onguti S, et al. Predictors of sepsis in     moderately severely injured patients: an analysis of the national     trauma data bank. Surgical infections. 2013; 14:62-68. -   25. Wibbenmeyer L, Danks R, Faucher L, et al. Prospective analysis     of nosocomial infection rates, antibiotic use, and patterns of     resistance in a burn population. J Burn Care Res. 2006; 27:152-160. -   26. Boomer J S, To K, Chang K C, et al. Immunosuppression in     patients who die of sepsis and multiple organ failure. JAMA: the     journal of the American Medical Association. 2011; 306:2594-2605. -   27. Lavrentieva A, Papadopoulou S, Kioumis J, et al. PCT as a     diagnostic and prognostic tool in burn patients. Whether time course     has a role in monitoring sepsis treatment. Burns. 2012; 38:356-363. -   28. Schultz L, Walker S A N, Elligsen M, et al. Identification of     predictors of early infection in acute burn patients. Burns. 2013;     39:1355-1366. -   29. Cuenca A G, Gentile L F, Lopez M C, et al. Development of a     Genomic Metric That Can Be Rapidly Used to Predict Clinical Outcome     in Severely Injured Trauma Patients. Crit Care Med. 2013;     41:1175-85. -   30. Laudanski K, Miller-Graziano C, Xiao W, et al. Cell-specific     expression and pathway analyses reveal alterations in trauma-related     human T cell and monocyte pathways. Proc Natl Acad Sci USA. 2006;     103:15564-15569. -   31. Xiao W, Mindrinos M N, Seok J, et al. A genomic storm in     critically injured humans. The Journal of experimental medicine.     2011; 208:2581-2590. -   32. Jeschke M G, Finnerty C C, Emdad F, et al. Mild Obesity Is     Protective After Severe Burn Injury. Annals of surgery. 2013;     Publish Ahead of Print:1. -   33. Wu Z, Irizarry R A, Gentleman R, et al. A model based background     adjustment for oligonucleotide expression arrays. Johns Hopkins     University, Dept. of Biostatistics Working Papers. 2004; -   34. Gentleman R C, Carey V J, Bates D M, et al. Bioconductor: open     software development for computational biology and bioinformatics.     Genome Biology. 2004; 5:R80. -   35. Kauffmann A, Gentleman R, and Huber W. arrayQualityMetrics—a     bioconductor package for quality assessment of microarray data.     Bioinformatics. 2009; 25:415-416. -   36. Servant N, Gravier E, Gestraud P, et al. EMA—A R package for     Easy Microarray data analysis. BMC research notes. 2010; 3:277. -   37. Smyth G K. Linear models and empirical bayes methods for     assessing differential expression in microarray experiments. Stat     Appl Genet Mol Biol. 2004; 3:Article3. -   38. Tibshirani R. Regression Shrinkage and Selection via the Lasso.     Journal of the Royal Statistical Society. Series B (Methodological).     1996; 58:267-288. -   39. Friedman J, Hastie T, and Tibshirani R. Regularization Paths for     Generalized Linear Models via Coordinate Descent. Journal of     statistical software. 2010; 33:1-22. -   40. Huang D W, Sherman B T, Stephens R, et al. DAVID gene ID     conversion tool. Bioinformation. 2008; 2:428-430. -   41. Wacharasint P, Boyd J H, Russell J A, et al. One size does not     fit all in severe infection: obesity alters outcome, susceptibility,     treatment, and inflammatory response. Crit Care. 2013; 17:R122. -   42. Johnson C A, Kleshchenko Y Y, Ikejiani A O, et al.     Thrombospondin-1 Interacts with Trypanosoma cruzi Surface     Calreticulin to Enhance Cellular Infection. PLoS One. 2012;     7:e40614. -   43. McMaken S, Exline M C, Mehta P, et al. Thrombospondin-1     Contributes to Mortality in Murine Sepsis through Effects on Innate     Immunity. PLoS One. 2011; 6:e19654. -   44. Streit M, Velasco P, Riccardi L, et al. Thrombospondin-1     suppresses wound healing and granulation tissue formation in the     skin of transgenic mice. The EMBO journal. 2000; 19:3272-3282. -   45. Shannon O. Platelets interact with bacterial pathogens.     Thrombosis and Haemostasis. 2009; 102:613-4. -   46. Carson W F, Cavassani K A, Dou Y, et al. Epigenetic regulation     of immune cell functions during post-septic immunosuppression.     Epigenetics: official journal of the DNA Methylation Society. 2011;     6:273-283. -   47. Smale S T. Selective transcription in response to an     inflammatory stimulus. Cell. 2010; 140:833-844. -   48. Perez-Campo F M, Costa G, Lie-a-Ling M, et al. The MYSTerious     MOZ, a histone acetyltransferase with a key role in haematopoiesis.     Immunology. 2013; 139:161-165. -   49. De Santa F, Narang V, Yap Z H, et al. Jmjd3 contributes to the     control of gene expression in LPS-activated macrophages. The EMBO     journal. 2009; 28:3341-3352. -   50. Kruidenier L, Chung C-W, Cheng Z, et al. A selective jumonji     H3K27 demethylase inhibitor modulates the proinflammatory macrophage     response. Nature. 2012; 488:404-408. -   51. Netea M G, Wijmenga C, and O'Neill L A J. Genetic variation in     Toll-like receptors and disease susceptibility. Nature Immunology.     2012; 13:535-542. -   52. Bronkhorst M W G A, Lomax M A Z, Vossen R H A M, et al. Risk of     infection and sepsis in severely injured patients related to single     nucleotide polymorphisms in the lectin pathway. British Journal of     Surgery. 2013; 100:1818-1826. -   53. Jannes G, and De Vos D. A review of current and future molecular     diagnostic tests for use in the microbiology laboratory. Methods Mol     Biol. 2006; 345:1-21. -   54. Pirnay J-P, De Vos D, Duinslaeger L, et al. Quantitation of     Pseudomonas aeruginosa in wound biopsy samples: from bacterial     culture to rapid ‘real-time’ polymerase chain reaction. Crit Care.     2000; 4:255. -   55. Chang S-S, Hsieh W-H, Liu T-S, et al. Multiplex PCR system for     rapid detection of pathogens in patients with presumed sepsis—a     systemic review and meta-analysis. PLoS One. 2013; 8:e62323. -   56. Skvarc M, Stubljar D, Rogina P, et al. Non-culture-based methods     to diagnose bloodstream infection: Does it work? Eur J Microbiol     Immunol (Bp). 2013; 3:97-104. -   57. Apidianakis Y, Que Y A, Xu W, et al. Down-regulation of     glutatione S-transferase 4 (hGSTA4) in the muscle of thermally     injured patients is indicative of susceptibility to bacterial     infection. The FASEB Journal. 2012; 26:730-737.

TABLE 1 Demographics and characteristics of participants Cases (≥2 Controls (≤1 Infectious Infectious Episodes All Episodes) [MIE]) (n = 113) (n = 47) (n = 66) P value Age when injured, mean (SD), y 37.7 (15.6) 37.0 (14.6) 38.2 (16.4) 0.681 Sex, n (%) males 90 (79.6%) 40 (85.1%) 50 (75.8%) 0.218 BMI Category, n (%) 0.888 Underweight 5 (4.4%) 1 (2.1%) 4 (6.1%) Healthy 44 (38.9%) 19 (40.4%) 25 (37.9%) Overweight 35 (31.0%) 15 (31.9%) 20 (30.3%) Obese 29 (25.7%) 12 (25.6%) 17 (25.8%) Severity of Injury APACHE II Score, median (IQR) 20 (12-26) 13 (8-20) 24 (18-28) <0.001* Burns size of TBSA, % (IQR) 40 (28-56) 32 (23-40) 46 (35-70) <0.001* Presence of Inhalation Injury, n (%) 49 (43.4%) 8 (17.0%) 41 (62.1%) <0.001* Outcome Hospital Stay, d (IQR) 35 (19-62) 20 (15-27) 60 (33-71) <0.001* Hospital Stay of Survived, d (IQR) 36 (19-62) 20.5 (15-27) 61 (44-72) <0.001* Days on Ventilation, d (IQR) 13 (2-33) 2 (0-5) 28 (13-40) <0.001* Day of Death Since Injury, d (IQR) 34 (18-63) 21 (18-21) 35.5 (18-65) 0.3753 Mortality, no. (%) 21 (18.6%) 3 (6.38%) 18 (27.3%) 0.0029* Number of Records by Type of Infection, n (%) Burn wound 332 (54.2%) 24 (60%) 308 (53.8%) Pneumonia 151 (24.7%) 8 (20%) 143 (25.0%) Bloodstream 59 (9.6%) 1 (2.5%) 58 (10.1%) Urinary tract 45 (7.4%) 7 (17.5%) 38 (6.6%) Catheter-related bloodstream 24 (3.9%) 0 (0%) 24 (4.2%) Pseudomembranous colitis 1 (0.2%) 0 (0%) 1 (0.2%) Number of Records by Isolated Pathogens, n (%) P. aeruginosa 92 (15.0%) 4 (10%) 88 (15.4%) S. aureus 81 (13.2%) 7 (17.5%) 74 (13.0%) Coagulase negative Staphylococci 77 (12.6%) 6 (15.0%) 71 (12.4%) Enterococcus 47 (7.7%) 4 (10.0%) 43 (7.5%) Acinetobacter 45 (7.4%) 1 (2.5%) 44 (7.7%) Candida species 43 (7.0%) 0 (0%) 43 (7.5%) E. coli 34 (5.6%) 1 (2.5%) 33 (5.8%) Enterobacter species 28 (4.6%) 1 (2.5%) 27 (4.7%) Gram negative NOS 27 (4.4%) 0 (0%) 27 (4.7%) K. pneumoniae 22 (3.6%) 0 (0%) 22 (3.8%) Others 116 (18.9%) 16 (40%) 100 (17.5%) *P < 0.05. Abbreviations: BMI, body mass index; IQR, inter-quartile range; TBSA, total body surface area.

TABLE 2 14 probe sets in the biomarker panel Gene Ontology Gene Biological Fold Probe set Symbol Gene Name Process Annotation Change Coefficients P value Upregulated 201109_s_at THBS1 thrombospondin 1 Angiogenesis, 3.37 0.560 <0.001 regulation of cytokine production, regulation of endothelial cell proliferation, regulation of antigen processing and presentation, regulation of immune system process 201110_s_at THBS1 thrombospondin 1 Same as above 2.31 0.100 0.001 201108_s_at THBS1 thrombospondin 1 Same as above 2.02 0.824 0.001 235412_at ARHGEF7 Rho guanine Apoptotic process, 1.86 0.747 0.017 nucleotide signal transduction, exchange factor epidermal growth (GEF) 7 factor receptor signaling pathway, small GTPase mediated signal transduction, apoptotic signaling pathway, lamellipodium assembly Down-regulated 217599_s_at MDFIC MyoD family Transcription, −2.34 −0.289 <0.001 inhibitor domain activation of JUN containing kinase activity, virus- host interaction, regulation of Wnt receptor signaling pathway, negative regulation of protein import into nucleus, positive regulation of viral transcription 200951_s_at CCND2 cyclin D2 Positive regulation of −2.21 0.292 <0.001 cyclin-dependent protein kinase activity, cell cycle, cell division 228986_at OSBPL8 oxysterol binding Lipid transport, −1.98 0.111 <0.001 protein-like 8 negative regulation of sequestering of triglyceride, fat cell differentiation 224730_at DCAF7 DDB1 and CUL4 Multicellular −1.87 −0.908 <0.001 associated factor 7 organismal development, protein ubiquitination 222907_x_at TMEM50B transmembrane NA −1.80 −0.335 <0.001 protein 50B 208797_s_at GOLGA8A/ golgin A8 family, NA −1.78 −1.068 <0.001 GOLGA8B member B 217656_at SMARCA4 SWI/SNF related, Negative regulation −1.59 0.252 <0.001 matrix associated, of transcription from actin dependent RNA polymerase II regulator of promoter, chromatin chromatin, remodeling, negative subfamily a, regulation of cell member 4 growth, negative regulation of androgen receptor signaling pathway, etc. 221248_s_at WHSC1L1 Wolf-Hirschhom Transcription, −1.51 −0.676 <0.001 syndrome regulation of candidate 1-like 1 transcription, cell growth, histone methylation, cell differentiation, histone lysine methylation 1556747_a_at NA NA NA −1.66 −0.786 0.005 1562957_at NA NA NA −1.64 −0.409 <0.001 P values were adjusted for multiple comparisons based on Benjamini-Hochberg method during the fold-change calculation of 26,107 probes after initial filtering (see Methods).

TABLE 3 Predicted early functional changes in case group that had MIE P Activation z- # of Functions annotation value score genes Increased Chemotaxis <0.001 3.924 55 Chemotaxis of cells <0.001 3.924 54 Homing of cells <0.001 3.815 59 Chemotaxis of leukocytes <0.001 3.795 37 Chemotaxis of phagocytes <0.001 3.546 30 Chemotaxis of myeloid cells <0.001 3.501 29 Homing of leukocytes <0.001 3.484 41 Replication of Influenza A virus <0.001 3.413 38 Replication of virus <0.001 3.314 64 Leukocyte migration <0.001 3.088 100 Inflammatory response <0.001 3.085 72 Viral infection <0.001 3.046 166 Cytostasis <0.001 2.913 30 Replication of RNA virus <0.001 2.782 56 Cell movement <0.001 2.766 173 Migration of cells <0.001 2.619 161 Tyrosine phosphorylation of protein <0.001 2.456 29 Recruitment of cells <0.001 2.451 34 Recruitment of granulocytes <0.001 2.405 26 Polarization of leukocytes <0.001 2.337 13 Recruitment of leukocytes <0.001 2.333 33 Adhesion of immune cells <0.001 2.271 40 Recruitment of myeloid cells <0.001 2.263 27 Adhesion of blood cells <0.001 2.250 41 Cell viability <0.001 2.240 112 Orientation of macrophages <0.001 2.200 6 Attachment of cells <0.001 2.166 18 Disassembly of focal adhesions <0.001 2.164 7 Formation of membrane ruffles <0.001 2.137 12 Cell survival <0.001 2.101 121 Cell movement of neutrophils <0.001 2.067 37 Invasion of breast cancer cell lines <0.001 2.064 25 Orientation of cells <0.001 2.028 19 Decreased <0.001 Development of lymphoid organ <0.001 −3.241 30 Development of lymphatic system <0.001 −2.970 41 component Bacterial infection <0.001 −2.890 47 Expansion of leukocytes <0.001 −2.753 25 Expansion of lymphocytes <0.001 −2.635 21 Development of lymph node <0.001 −2.608 14 Morphology of germinal center <0.001 −2.415 11 Morphology of lymph follicle <0.001 −2.415 15 Expansion of blood cells <0.001 −2.384 26 Encephalitis <0.001 −2.374 27 Inflammation of organ <0.001 −2.362 97 Quantity of neutrophils 0.0011 −2.208 23 Development of thymocytes <0.001 −2.189 13 Quantity of granulocytes <0.001 −2.133 36 Organismal death <0.001 −2.074 196 An absolute z-score of ≥2 was designated as significant by the IPA software. The numbers of genes used to predict functional changes are indicated in the column with the heading “# of genes”.

TABLE 11 Genes involved in epigenetic modulation and chromatin remodeling from the 1142 probe sets. Adjusted P value is based on B-H method. Gene symbols in bold are the genes that are part of the biomarker panel. Adjusted ID Symbol Gene Name Fold Change P value 201715_s_at ACIN1 apoptotic chromatin condensation inducer 1 1.833 0.029 1553685_s_at SP1 Sp1 transcription factor 1.832 0.030 41386_i_at KDM6B lysine (K)-specific demethylase 6B 1.767 0.019 208686_s_at BRD2 bromodomain containing 2 1.614 0.086 213146_at KDM6B lysine (K)-specific demethylase 6B 1.607 0.094 202383_at KDM5C lysine (K)-specific demethylase 5C 1.548 0.010 215616_s_at KDM4B lysine (K)-specific demethylase 4B 1.545 0.072 201353_s_at BAZ2A bromodomain adjacent to zinc finger domain, 2A 1.503 0.022 210387_at HIST2H2BE(includes others) histone cluster 2, H2be −1.506 0.075 228287_at ING5 inhibitor of growth family, member 5 −1.507 0.011 225253_s_at METTL2A methyltransferase like 2A −1.514 0.008 221248_s_at WHSC1L1 Wolf-Hirschhorn syndrome candidate 1-like 1 −1.515 9.28E−05 218166_s_at RSF1 remodeling and spacing factor 1 −1.516 0.002 231913_s_at BRCC3 BRCA1/BRCA2-containing complex, subunit 3 −1.523 0.002 239784_at NA NA −1.526 0.000 209715_at CBX5 (HP1alpha) chromobox homolog 5 −1.532 0.003 213971_s_at SUZ12 suppressor of zeste 12 homolog (Drosophila) −1.534 0.001 203204_s_at KDM4A lysine (K)-specific demethylase 4A −1.565 4.86E−04 205659_at HDAC9 histone deacetylase 9 −1.573 0.004 217656_at SMARCA4 SWI/SNF related, matrix associated, −1.590 5.77E−05 actin dependent regulator of chromatin, subfamily a, member 4 243552_at MBTD1 mbt domain containing 1 −1.591 0.002 244443_at CHD2 chromodomain helicase DNA binding protein 2 −1.610 0.013 1554667_s_at METTL8 methyltransferase like 8 −1.610 0.003 216521_s_at BRCC3 BRCA1/BRCA2-containing complex, subunit 3 −1.613 0.002 235338_s_at SETDB2 SET domain, bifurcated 2 −1.617 3.46E−04 1569385_s_at TET2 tet methylcytosine dioxygenase 2 −1.630 0.012 229586_at CHD9 chromodomain helicase DNA binding protein 9 −1.632 0.001 225455_at TADA1 transcriptional adaptor 1 −1.654 0.001 201072_s_at SMARCC1 SWI/SNF related, matrix associated, −1.657 1.44E−04 actin dependent regulator of chromatin, subfamily c, member 1 220792_at PRDM5 PR domain containing 5 −1.738 0.005 207156_at HIST1 H2AG (includes others) histone cluster 1, H2ag −1.742 0.009 227075_at ELP3 elongator acetyltransferase complex subunit 3 −1.756 0.003 238220_at KDM6A lysine (K)-specific demethylase 6A −1.761 0.004 1555920_at CBX3 (HP1gamma) chromobox homolog 3 −1.838 0.001 222873_s_at EHMT1 euchromatic histone-lysine N-methyltransferase 1 −1.868 6.92E−05 230629_s_at EP400 E1A binding protein p400 −1.987 2.38E−04 216361_s_at KAT6A K(lysine) acetyltransferase 6A −2.018 0.010 220946_s_at SETD2 SET domain containing 2 −2.048 7.65E−05 216069_at PRMT2 protein arginine methyltransferase 2 −2.085 0.006 242918_at NASP nuclear autoantigenic sperm protein −2.098 2.62E−04 (histonebinding) 203056_s_at PRDM2 PR domain containing 2, with ZNF domain −2.164 1.44E−04 235461_at TET2 tet methylcytosine dioxygenase 2 −2.912 0.001

TABLE 12 Estimates of multivariate logistic regression models. Covariates Estimates Standard Error P value Clinical Model Intercept −1.9885 0.4735 <.001 TBSA 0.0753 0.0186 <.001 Age 0.0392 0.0169 0.0203 Inhalation Injury (Yes) 1.9376 0.5248 <.001 Genomic Model Intercept 0.7449 0.3556 0.0362 1556747_a_at −0.7855 0.383 0.0403 1562957_at −0.4094 0.7305 0.5752 200951_s_at 0.2915 0.6202 0.6383 201108_s_at 0.8238 0.4333 0.0573 201109_s_at 0.5597 0.4199 0.1826 201110_s_at 0.0998 0.5276 0.85 208797_s_at −1.0683 0.6742 0.113 217599_s_at −0.2885 0.4856 0.5524 217656_at 0.2524 0.8757 0.7732 221248_s_at −0.6759 0.7991 0.3976 222907_x_at −0.3347 0.7969 0.6745 224730_at −0.9083 0.6465 0.1601 228986_at 0.1106 0.5772 0.848 235412_at 0.7468 0.2806 0.0078 Combined Model Intercept −1.1912 0.8375 0.1549 TBSA 0.0423 0.0254 0.0959 Age 0.0652 0.0412 0.1138 Inhalation Injury (Yes) 3.5132 1.3252 0.008 1556747_a_at −0.6652 0.4794 0.1653 1562957_at 0.803 1.139 0.4808 200951_s_at 0.033 0.7811 0.9663 201108_s_at 0.8321 0.5618 0.1385 201109_s_at 0.8448 0.5465 0.1221 201110_s_at 0.0714 0.6752 0.9158 208797_s_at −0.731 0.785 0.3518 217599_s_at −0.146 0.5532 0.7918 217656_at −1.0108 1.2418 0.4157 221248_s_at −1.2438 1.3393 0.353 222907_x_at −0.167 0.9343 0.8582 224730_at −1.4905 0.8 0.0625 228986_at 0.1821 0.7275 0.8023 235412_at 0.8709 0.3909 0.0259

TABLE 13 Term centric singular enrichment in gene ontology biological process and molecular function of the 1142 probe sets. Fold Adjusted GO Term Count % Enrichment P value Immune Epi Transcription Metabolism BP GO:0001775~cell activation 42 4.5 2.76 9.30E−06 * BP GO:0007242~intracellular signaling 114 12.2 1.71 9.52E−06 * cascade BP GO:0045321~leukocyte activation 38 4.1 2.96 1.63E−05 ** BP GO:0016192~vesicle-mediated transport 64 6.9 2.09 2.33E−05 * BP GO:0016568~chromatin modification 37 4.0 2.54 2.66E−04 ** BP GO:0046649~lymphocyte activation 30 3.2 2.84 2.99E−04 ** BP GO:0006897~endocytosis 32 3.4 2.74 3.07E−04 ** BP GO:0010324~membrane invagination 32 3.4 2.74 3.07E−04 * BP GO:0016044~membrane organization 45 4.8 2.23 3.53E−04 * BP GO:0010557~positive regulation of 64 6.9 1.84 7.69E−04 ** macromolecule biosynthetic process BP GO:0031328~positive regulation of cellular 66 7.1 1.82 8.02E−04 ** biosynthetic process BP GO:0042110~T cell activation 22 2.4 3.29 8.36E−04 ** BP GO:0007243~protein kinase cascade 43 4.6 2.19 8.68E−04 * BP GO:0006955~immune response 66 7.1 1.80 9.34E−04 ** BP GO:0009891~positive regulation of 66 7.1 1.79 0.001 ** biosynthetic process BP GO:0010604~positive regulation of 77 8.3 1.69 0.001 ** macromolecule metabolic process BP GO:0042981~regulation of apoptosis 73 7.8 1.71 0.001 * BP GO:0030036~actin cytoskeleton 30 3.2 2.50 0.002 organization BP GO:0018105~peptidyl-serine 10 1.1 6.50 0.002 * phosphorylation BP GO:0030029~actin filament-based 31 3.3 2.42 0.002 process BP GO:0006325~chromatin organization 42 4.5 2.09 0.002 ** BP GO:0010941~regulation of cell death 73 7.8 1.69 0.002 * BP GO:0043067~regulation of programmed cell 73 7.8 1.69 0.002 * death BP GO:0006793~phosphorus metabolic 84 9.0 1.63 0.002 ** process BP GO:0006796~phosphate metabolic 84 9.0 1.63 0.002 ** process BP GO:0016310~phosphorylation 72 7.7 1.70 0.002 MF GO:0019899~enzyme binding 55 5.9 1.96 0.002 BP GO:0046907~intracellular transport 61 6.5 1.75 0.003 BP GO:0018209~peptidyl-serine 11 1.2 5.31 0.003 * modification BP GO:0002684~positive regulation of 30 3.2 2.37 0.003 ** immune system process BP GO:0008219~cell death 65 7.0 1.70 0.003 BP GO:0016265~death 65 7.0 1.69 0.004 BP GO:0006468~protein amino acid 61 6.5 1.72 0.004 * * phosphorylation BP GO:0007265~Ras protein signal 18 1.9 3.23 0.004 transduction BP GO:0048534~hemopoietic or lymphoid 31 3.3 2.25 0.005 ** organ development BP GO:0051173~positive regulation of 59 6.3 1.73 0.005 ** nitrogencompound metabolic process BP GO:0045893~positive regulation of 47 5.0 1.86 0.005 ** transcription, DNA-dependent BP GO:0002694~regulation of leukocyte 23 2.5 2.61 0.006 ** activation BP GO:0051254~positive regulation of 47 5.0 1.84 0.006 ** RNA metabolic process BP GO:0012501~programmed cell death 56 6.0 1.73 0.006 * BP GO:0042325~regulation of 46 4.9 1.86 0.006 * * phosphorylation BP GO:0045935~positive regulation of 57 6.1 1.72 0.006 ** nucleobase, nucleoside, nucleotide and nucleic acid metabolic process BP GO:0018210~peptidyl-threonine 8 0.9 7.18 0.006 * modification BP GO:0007264~small GTPase mediated 34 3.6 2.10 0.006 signal transduction BP GO:0002263~cell activation during 10 1.1 5.23 0.006 ** immune response BP GO:0002366~leukocyte activation 10 1.1 5.23 0.006 ** during immune response BP GO:0051276~chromosome organization 47 5.0 1.83 0.006 ** BP GO:0051174~regulation of phosphorus 47 5.0 1.83 0.006 ** metabolic process BP GO:0019220~regulation of phosphate 47 5.0 1.83 0.006 ** metabolic process BP GO:0045941~positive regulation of 52 5.6 1.74 0.009 ** transcription BP GO:0030097~hemopoiesis 28 3.0 2.24 0.009 ** BP GO:0060627~regulation of vesicle- 16 1.7 3.14 0.010 * mediated transport BP GO:0050865~regulation of cell 23 2.5 2.48 0.010 ** activation BP GO:0002520~immune system 31 3.3 2.12 0.010 ** development BP GO:0007568~aging 17 1.8 2.91 0.014 BP GO:0006357~regulation of transcription 62 6.6 1.61 0.014 ** fromRNA polymerase II promoter BP GO:0033674~positive regulation of 27 2.9 2.20 0.014 * kinase activity BP GO:0002252~immune effector process 19 2.0 2.67 0.014 ** BP GO:0008380~RNA splicing 31 3.3 2.06 0.014 ** BP GO:0018107~peptidyl-threonine 7 0.8 7.33 0.014 * phosphorylation BP GO:0009991~response to extracellular 26 2.8 2.23 0.015 * * stimulus BP GO:0010628~positive regulation of gene 52 5.6 1.69 0.015 ** expression MF GO:0003723~RNA binding 65 7.0 1.69 0.015 * * BP GO:0030098~lymphocyte 16 1.7 2.93 0.017 ** differentiation BP GO:0043549~regulation of kinase 36 3.9 1.90 0.017 * activity BP GO:0045860~positive regulation of 26 2.8 2.20 0.017 * protein kinase activity BP GO:0031667~response to nutrient 24 2.6 2.30 0.017 ** levels BP GO:0010033~response to organic 61 6.5 1.59 0.017 ** substance MF GO:0030695~GTPase regulator activity 42 4.5 1.94 0.017 BP GO:0044093~positive regulation of 52 5.6 1.67 0.017 molecular function BP GO:0007015~actin filament organization 13 1.4 3.40 0.018 * BP GO:0032268~regulation of cellular 44 4.7 1.75 0.019 ** protein metabolic process BP GO:0007584~response to nutrient 19 2.0 2.56 0.020 ** BP GO:0051347~positive regulation of 27 2.9 2.12 0.020 transferase activity MF GO:0060589~nucleoside-triphosphatase 42 4.5 1.90 0.021 regulator activity BP GO:0002696~positive regulation of 16 1.7 2.84 0.021 ** leukocyte activation MF GO:0032553~ribonucleotide binding 133 14.3 1.35 0.021 * MF GO:0032555~purine ribonucleotide 133 14.3 1.35 0.021 binding BP GO:0045597~positive regulation of cell 26 2.8 2.14 0.022 ** differentiation MF GO:0016278~lysine N-methyltransferas 9 1.0 5.25 0.023 * activity MF GO:0016279~protein-ly sine 9 1.0 5.25 0.023 * Nmethyltransferase activity MF GO:0018024~histone-lysine 9 1.0 5.25 0.023 ** Nmethyltransferase activity BP GO:0051129~negative regulation of 19 2.0 2.52 0.023 cellular component organization MF GO:0042054~histone 10 1.1 4.78 0.024 ** methyltransferase activity MF GO:0000166~nucleotide binding 158 16.9 1.31 0.024 * BP GO:0002521~leukocyte differentiation 18 1.9 2.59 0.024 ** BP GO:0030217~T cell differentiation 12 1.3 3.48 0.024 ** BP GO:0001817~regulation of cytokine 22 2.4 2.29 0.026 ** production BP GO:0006915~apoptosis 52 5.6 1.63 0.026 * BP GO:0033273~response to vitamin 12 1.3 3.43 0.026 ** BP GO:0002819~regulation of adaptive 11 1.2 3.70 0.027 ** immune response BP GO:0007266~Rho protein signal 9 1.0 4.46 0.028 transduction BP GO:0051338~regulation of transferase 36 3.9 1.82 0.028 activity BP GO:0050867~positive regulation of cell 16 1.7 2.72 0.029 ** activation BP GO:0016197~endosome transport 11 1.2 3.57 0.031 * BP GO:0001932~regulation of protein 21 2.3 2.29 0.032 amino acid phosphorylation BP GO:0010608~posttranscriptional 24 2.6 2.14 0.032 ** ** regulation of gene expression BP GO:0051094~positive regulation of 29 3.1 1.97 0.032 ** developmental process BP GO:0010605~negative regulation of 60 6.4 1.54 0.032 ** macromolecule metabolic process MF GO:0005083~small GTPase regulator 30 3.2 2.04 0.033 activity BP GO:0045449~regulation of transcription 172 18.4 1.25 0.035 ** BP GO:0007010~cytoskeleton organization 40 4.3 1.73 0.035 * MF GO:0004674~protein serine/threonine 41 4.4 1.78 0.035 kinase activity MF GO:0051015~actin filament binding 11 1.2 3.87 0.036 * MF GO:0005524~ATP binding 108 11.6 1.36 0.038 MF GO:0016563~transcription activator 39 4.2 1.77 0.040 ** activity MF GO:0042802~identical protein binding 55 5.9 1.60 0.041 BP GO:0016071~mRNA metabolic process 35 3.8 1.78 0.044 ** BP GO:0043405~regulation of MAP kinase 18 1.9 2.41 0.045 ** activity BP GO:0050863~regulation of T cell 16 1.7 2.58 0.045 ** activation MF GO:0005070~SH3/SH2 adaptor activity 10 1.1 3.81 0.047 BP GO:0043065~positive regulation of 39 4.2 1.71 0.047 * apoptosis MF GO:0032559~adenyl ribonucleotide 108 11.6 1.35 0.049 binding MF GO:0017076~purine nucleotide binding 133 14.3 1.29 0.049 BP GO:0045859~regulation of protein 33 3.5 1.80 0.050 kinase activity Abbreviations: BP, biological process; MF, molecular function. Adjust P value is based on Benjamini method. Astericks indicate whether this term is associated with one of the four functional categories: immune responses, epugenetic modulation, transcription and metabolism. * denotes associated; ** denotes highly associated; based on manual curation.

TABLE 14 Term centric functional annotation clustering that shows annotation groups that are encriched for the 1142 probe sets. Adjusted Fold Category Term Count % P value P value Enrichment FDR Annotation Cluster 1 Enrichment Score: 6.51 BP GO:0016192~vesicle-mediated transport 64 6.86 2.98E−08 2.33E−05 2.09 5.39E−05 BP GO:0010324~membrane invagination 32 3.43 5.90E−07 3.07E−04 2.74 1.07E−03 BP GO:0006897~endocytosis 32 3.43 5.90E−07 3.07E−04 2.74 1.07E−03 BP GO:0016044~membrane organization 45 4.82 9.05E−07 3.53E−04 2.23 1.64E−03 Annotation Cluster 2 Enrichment Score: 4.53 BP GO:0045321~leukocyte activation 38 4.07 5.21E−09 1.63E−05 2.96 9.42E−06 BP GO:0001775~cell activation 42 4.50 5.95E−09 9.30E−06 2.76 1.08E−05 BP GO:0046649~lymphocyte activation 30 3.22 6.71E−07 2.99E−04 2.84 1.21E−03 BP GO:0042110~T cell activation 2 2 2.36 2.68E−06 8.36E−04 3.29 4.85E−03 BP GO:0048534~hemopoietic or lymphoid organ 31 3.32 4.96E−05 4.68E−03 2.25 0.09 development BP GO:0030097~hemopoiesis 28 3.00 1.36E−04 9.38E−03 2.24 0.25 BP GO:0002520~immune system development 31 3.32 1.49E−04 9.82E−03 2.12 0.27 BP GO:0030098~lymphocyte differentiation 16 1.71 3.32E−04 1.66E−02 2.93 0.60 BP GO:0002521~leukocyte differentiation 18 1.93 5.50E−04 2.42E−02 2.59 0.99 BP GO:0030217~T cell differentiation 12 1.29 5.58E−04 2.43E−02 3.48 1.01 BP GO:0042113~B cell activation 11 1.18 6.61E−03 0.14 2.73 11.30 BP GO:0030183~B cell differentiation 8 0.86 0.01 0.21 3.14 20.52 Annotation Cluster 3 Enrichment Score: 4.33 BP GO:0018105~peptidyl-serine phosphorylation 10 1.07 1.21E−05 1.57E−03 6.50 0.02 BP GO:0018209~peptidyl-serine modification 11 1.18 2.57E−05 2.97E−03 5.31 0.05 BP GO:0018210~peptidyl-threonine modification 8 0.86 6.90E−05 5.97E−03 7.18 0.12 BP GO:0018107~peptidyl-threonine 7 0.75 2.33E−04 0.01 7.33 0.42 phosphorylation Annotation Cluster 4 Enrichment Score: 4.11 BP GO:0030036~actin cytoskeleton organization 30 3.22 9.00E−06 1.56E−03 2.50 0.02 BP GO:0030029~actin filament-based process 31 3.32 1.16E−05 1.57E−03 2.42 0.02 BP GO:0007015~actin filament organization 13 1.39 3.67E−04 0.02 3.40 0.66 BP GO:0007010~cytoskeleton organization 40 4.29 9.47E−04 0.03 1.73 1.70 Annotation Cluster 5 Enrichment Score: 4.08 BP GO:0008219~cell death 65 6.97 2.83E−05 3.16E−03 1.70 0.05 BP GO:0016265~death 65 6.97 3.50E−05 3.63E−03 1.69 0.06 BP GO:0012501~programmed cell death 56 6.00 7.74E−05 5.88E−03 1.73 0.14 BP GO:0006915~apoptosis 52 5.57 5.99E−04 0.03 1.63 1.08 Annotation Cluster 6 Enrichment Score: 3.74 BP GO:0016568~chromatin modification 37 3.97 4.25E−07 2.66E−04 2.54 7.69E−04 BP GO:0006325~chromatin organization 42 4.50 1.01E−05 1.58E−03 2.09 0.02 BP GO:0051276~chromosome organization 47 5.04 8.94E−05 6.47E−03 1.83 0.16 BP GO:0016569~covalent chromatin modification 16 1.71 2.72E−03 0.08 2.39 4.80 BP GO:0016570~histone modification 15 1.61 5.16E−03 0.12 2.32 8.94 BP GO:0006730~one-carbon metabolic process 14 1.50 6.27E−03 0.14 2.36 10.76 Annotation Cluster 7 Enrichment Score: 3.54 BP GO:0006796~phosphate metabolic process 84 9.00 8.98E−06 1.65E−03 1.63 0.02 BP GO:0006793~phosphorus metabolic process 84 9.00 8.98E−06 1.65E−03 1.63 0.02 BP GO:0016310~phosphorylation 72 7.72 1.12E−05 1.66E−03 1.70 0.02 BP GO:0006468~protein amino acid 61 6.54 3.71E−05 3.73E−03 1.72 0.07 phosphorylation MF GO:0000166~nucleotide binding 158 16.93 1.43E−04 0.02 1.31 0.22 MF GO:0032553~ribonucleotide binding 133 14.26 1.76E−04 0.02 1.35 0.27 MF GO:0032555~purine ribonucleotide binding 133 14.26 1.76E−04 0.02 1.35 0.27 MF GO:0004674~protein serine/threonine kinase 41 4.39 4.62E−04 0.03 1.78 0.71 activity MF GO:0005524~ATP binding 108 11.58 6.02E−04 0.04 1.36 0.93 MF GO:0032559~adenyl ribonucleotide binding 108 11.58 9.54E−04 0.05 1.35 1.46 MF GO:0017076~purine nucleotide binding 133 14.26 1.02E−03 0.05 1.29 1.56 MF GO:0004672~protein kinase activity 50 5.36 2.57E−03 0.09 1.54 3.90 MF GO:0001882~nucleoside binding 111 11.90 3.86E−03 0.12 1.28 5.80 MF GO:0001883~purine nucleoside binding 110 11.79 4.30E−03 0.12 1.28 6.45 MF GO:0030554~adenyl nucleotide binding 108 11.58 5.30E−03 0.13 1.28 7.88 Annotation Cluster 8 Enrichment Score: 3.42 BP GO:0010557~positive regulation of 64 6.86 2.71E−06 7.69E−04 1.84 0.00 macromolecule biosynthetic process BP GO:0031328~positive regulation of cellular 66 7.07 3.08E−06 8.02E−04 1.82 0.01 biosynthetic process BP GO:0009891~positive regulation of 66 7.07 5.00E−06 1.12E−03 1.79 0.01 biosynthetic process BP GO:0010604~positive regulation of 77 8.25 5.58E−06 1.16E−03 1.69 0.01 macromolecule metabolic process BP GO:0051173~positive regulation of nitrogen 59 6.32 4.88E−05 4.75E−03 1.73 0.09 compound metabolic process BP GO:0045893~positive regulation of 47 5.04 6.00E−05 5.50E−03 1.86 0.11 transcription, DNA-dependent BP GO:0045935~positive regulation of nucleobase, 57 6.11 7.28E−05 5.96E−03 1.72 0.13 nucleoside, nucleotide and nucleic acid metabolic process BP GO:0051254~positive regulation of RNA 47 5.04 7.35E−05 5.87E−03 1.84 0.13 metabolic process BP GO:0045941~positive regulation of 52 5.57 1.26E−04 8.93E−03 1.74 0.23 transcription BP GO:0006357~regulation of transcription from 62 6.65 2.35E−04 0.01 1.61 0.42 RNA polymerase II promoter BP GO:0010628~positive regulation of gene 52 5.57 2.61E−04 0.01 1.69 0.47 expression BP GO:0045449~regulation of transcription 172 18.44 9.56E−04 0.03 1.25 1.72 BP GO:0051252~regulation of RNA metabolic 124 13.29 1.93E−03 0.06 1.29 3.44 process BP GO:0045944~positive regulation of 33 3.54 4.56E−03 0.11 1.68 7.94 transcription from RNA polymerase II promoter BP GO:0006355~regulation of transcription, 118 12.65 6.39E−03 0.14 1.25 10.95 DNA-dependent BP GO:0006350~transcription 136 14.58 8.00E−03 0.16 1.22 13.52 MF GO:0030528~transcription regulator activity 102 10.93 1.03E−02 0.20 1.26 14.84 MF GO:0003677~DNA binding 132 14.15 2.81E−01 0.88 1.06 99.40 MF GO:0003700~transcription factor activity 56 6.00 3.59E−01 0.92 1.07 99.90 Annotation Cluster 9 Enrichment Score: 3.31 MF GO:0042054~histone methyltransferase activity 10 1.07 1.70E−04 0.02 4.78 0.26 MF GO:0016278~lysine N-methyltransferase 9 0.96 2.16E−04 0.02 5.25 0.33 activity MF GO:0016279~protein-lysine 9 0.96 2.16E−04 0.02 5.25 0.33 N-methyltransferase activity MF GO:0018024~histone-lysine 9 0.96 2.16E−04 0.02 5.25 0.33 N-methyltransferase activity MF GO:0008276~protein methyltransferase activity 10 1.07 1.19E−03 0.05 3.73 1.82 MF GO:0008170~N-methyltransferase activity 9 0.96 6.78E−03 0.16 3.17 9.98 Annotation Cluster 10 Enrichment Score: 2.96 BP GO:0042981~regulation of apoptosis 73 7.82 7.19E−06 1.40E−03 1.71 0.01 BP GO:0043067~regulation of programmed cell 73 7.82 9.92E−06 1.63E−03 1.69 0.02 death BP GO:0010941~regulation of cell death 73 7.82 1.13E−05 1.60E−03 1.69 0.02 BP GO:0043065~positive regulation of apoptosis 39 4.18 1.37E−03 0.05 1.71 2.45 BP GO:0043068~positive regulation of 39 4.18 1.55E−03 0.05 1.70 2.76 programmed cell death BP GO:0010942~positive regulation of cell death 39 4.18 1.67E−03 0.05 1.69 2.98 BP GO:0043066~negative regulation of apoptosis 33 3.54 2.23E−03 0.07 1.76 3.96 BP GO:0043069~negative regulation of 33 3.54 2.77E−03 0.08 1.73 4.89 programmed cell death BP GO:0060548~negative regulation of cell death 33 3.54 2.89E−03 0.08 1.73 5.10 BP GO:0006916~anti-apoptosis 22 2.36 3.09E−03 0.08 2.01 5.44 BP GO:0006917~induction of apoptosis 28 3.00 1.15E−02 0.20 1.65 18.82 BP GO:0012502~induction of programmed 28 3.00 1.19E−02 0.20 1.64 19.49 cell death BP GO:0008624~induction of apoptosis by 10 1.07 1.40E−01 0.73 1.68 93.41 extracellular signals Annotation Cluster 11 Enrichment Score: 2.90 BP GO:0042325~regulation of phosphorylation 46 4.93 6.99E−05 5.88E−03 1.86 0.13 BP GO:0019220~regulation of phosphate 47 5.04 8.94E−05 6.47E−03 1.83 0.16 metabolic process BP GO:0051174~regulation of phosphorus 47 5.04 8.94E−05 6.47E−03 1.83 0.16 metabolic process BP GO:0033674~positive regulation of kinase 27 2.89 2.33E−04 0.01 2.20 0.42 activity BP GO:0044093~positive regulation of molecular 52 5.57 3.19E−04 0.02 1.67 0.58 function BP GO:0045860~positive regulation of protein 26 2.79 3.25E−04 0.02 2.20 0.59 kinase activity BP GO:0043549~regulation of kinase activity 36 3.86 3.29E−04 0.02 1.90 0.59 BP GO:0032268~regulation of cellular protein 44 4.72 3.96E−04 0.02 1.75 0.71 metabolic process BP GO:0051347~positive regulation of transferase 27 2.89 4.23E−04 0.02 2.12 0.76 activity BP GO:0051338~regulation of transferase activity 36 3.86 7.03E−04 0.03 1.82 1.26 BP GO:0001932~regulation of protein amino acid 21 2.25 8.46E−04 0.03 2.29 1.52 phosphorylation BP GO:0043405~regulation of MAP kinase activity 18 1.93 1.27E−03 0.04 2.41 2.27 BP GO:0045859~regulation of protein kinase 33 3.54 1.47E−03 0.05 1.80 2.63 activity BP GO:0000165~MAPKKK cascade 21 2.25 1.81E−03 0.06 2.15 3.22 BP GO:0043406~positive regulation of MAP 14 1.50 2.80E−03 0.08 2.59 4.94 kinase activity BP GO:0031399~regulation of protein modification 28 3.00 4.01E−03 0.10 1.79 7.02 process BP GO:0043085~positive regulation of catalytic 42 4.50 7.01E−03 0.14 1.52 11.94 activity BP GO:0043507~positive regulation of JUN kinase 6 0.64 2.53E−02 0.33 3.53 37.09 activity BP GO:0000187~activation of MAPK activity 10 1.07 2.91E−02 0.36 2.30 41.43 BP GO:0043408~regulation of MAPKKK cascade 12 1.29 2.96E−02 0.36 2.07 41.87 BP GO:0032147~activation of protein kinase 12 1.29 3.92E−02 0.42 1.98 51.49 activity Annotation Cluster 12 Enrichment Score: 2.78 MF GO:0042802~identical protein binding 55 5.89 5.91E−04 0.04 1.60 0.91 MF GO:0042803~protein homodimerization activity 32 3.43 2.01E−03 0.08 1.79 3.07 MF GO:0046983~protein dimerization activity 45 4.82 3.81E−03 0.12 1.55 5.73 Annotation Cluster 13 Enrichment Score: 2.76 BP GO:0009991~response to extracellular stimulus 26 2.79 2.64E−04 0.01 2.23 0.48 BP GO:0031667~response to nutrient levels 24 2.57 3.10E−04 0.02 2.30 0.56 BP GO:0007584~response to nutrient 19 2.04 4.28E−04 0.02 2.56 0.77 BP GO:0033273~response to vitamin 12 1.29 6.39E−04 0.03 3.43 1.15 BP GO:0033189~response to vitamin A 8 0.86 6.08E−03 0.13 3.59 10.44 BP GO:0032526~response to retinoic acid 7 0.75 7.04E−03 0.14 4.00 12.00 BP GO:0033280~response to vitamin D 4 0.43 4.96E−02 0.47 4.71 60.12 Annotation Cluster 14 Enrichment Score: 2.70 BP GO:0002263~cell activation during immune 10 1.07 8.11E−05 6.01E−03 5.23 0.15 response BP GO:0002366~leukocyte activation during 10 1.07 8.11E−05 6.01E−03 5.23 0.15 immune response BP GO:0002285~lymphocyte activation during 6 0.64 1.98E−03 0.06 6.28 3.53 immune response BP GO:0002274~myeloid leukocyte activation 9 0.96 2.61E−03 0.07 3.69 4.61 BP GO:0002286~T cell activation during immune 4 0.43 2.85E−02 0.35 5.80 40.68 response BP GO:0002275~myeloid cell activation during 4 0.43 6.68E−02 0.54 4.19 71.37 immune response Annotation Cluster 15 Enrichment Score: 2.54 BP GO:0008380~RNA splicing 31 3.32 2.46E−04 0.01 2.06 0.44 BP GO:0016071~mRNA metabolic process 35 3.75 1.25E−03 0.04 1.78 2.24 BP GO:0000377~RNA splicing, via 18 1.93 3.07E−03 0.08 2.22 5.41 transesterification reactions with bulged adenosine as nucleophile BP GO:0000375~RNA splicing, via 18 1.93 3.07E−03 0.08 2.22 5.41 transesterification reactions BP GO:0000398~nuclear mRNA splicing, via 18 1.93 3.07E−03 0.08 2.22 5.41 spliceosome BP GO:0006397~mRNA processing 30 3.22 3.53E−03 0.09 1.76 6.20 BP GO:0006396~RNA processing 39 4.18 5.25E−02 0.48 1.34 62.31 Annotation Cluster 16 Enrichment Score: 2.47 MF GO:0005070~SH3/SH2 adaptor activity 10 1.07 1.02E−03 0.05 3.81 1.57 MF GO:0030674~protein binding, bridging 13 1.39 4.27E−03 0.12 2.58 6.40 MF GO:0060090~molecular adaptor activity 10 1.07 9.07E−03 0.19 2.78 13.14 Annotation Cluster 17 Enrichment Score: 2.45 BP GO:0002684~positive regulation of immune 30 3.22 2.42E−05 0.00 2.37 0.04 system process BP GO:0001817~regulation of cytokine production 22 2.36 6.05E−04 0.03 2.29 1.09 BP GO:0001819~positive regulation of cytokine 13 1.39 2.74E−03 0.08 2.72 4.85 production BP GO:0050778~positive regulation of immune 17 1.82 4.29E−03 0.11 2.21 7.48 response BP GO:0048584~positive regulation of response to 22 2.36 1.40E−02 0.22 1.76 22.56 stimulus BP GO:0032649~regulation of interferon-gamma 6 0.64 1.95E−02 0.28 3.77 29.99 production BP GO:0051240~positive regulation of 18 1.93 1.51E−01 0.75 1.39 94.78 multicellular organismal process Annotation Cluster 18 Enrichment Score: 2.19 BP GO:0043488~regulation of mRNA stability 6 0.64 5.11E−03 0.12 5.14 8.85 BP GO:0048255~mRNA stabilization 5 0.54 6.68E−03 0.14 6.28 11.42 BP GO:0043489~RNA stabilization 5 0.54 6.68E−03 0.14 6.28 11.42 BP GO:0043487~regulation of RNA stability 6 0.64 7.56E−03 0.15 4.71 12.82 Annotation Cluster 19 Enrichment Score: 2.11 MF GO:0030695~GTPase regulator activity 42 4.50 6.06E−05 0.02 1.94 0.09 MF GO:00605 89~nucleoside-triphosphatase 42 4.50 9.85E−05 0.02 1.90 0.15 regulator activity MF GO:0005083~small GTPase regulator activity 30 3.22 3.54E−04 0.03 2.04 0.55 MF GO:0005096~GTPase activator activity 23 2.47 3.55E−03 0.12 1.95 5.34 MF GO:0008047~enzyme activator activity 29 3.11 1.30E−02 0.22 1.61 18.37 BP GO:0051056~regulation of small GTPase 23 2.47 1.46E−02 0.23 1.72 23.32 mediated signal transduction MF GO:0005085~guanyl-nucleotide exchange 16 1.71 1.62E−02 0.25 1.96 22.33 factor activity MF GO:0005099~Ras GTPase activator activity 11 1.18 2.34E−02 0.30 2.25 30.61 BP GO:0046578~regulation of Ras protein signal 19 2.04 3.03E−02 0.36 1.70 42.72 transduction BP GO:0035023~regulation of Rho protein signal 10 1.07 7.90E−02 0.58 1.90 77.45 transduction MF GO:0005088~Ras guanyl-nucleotide exchange 8 0.86 1.91E−01 0.79 1.70 96.25 factor activity MF GO:0005089~Rho guanyl-nucleotide exchange 7 0.75 2.04E−01 0.80 1.76 97.05 factor activity Annotation Cluster 20 Enrichment Score: 2.09 MF GO:0016563~transcription activator activity 39 4.18 6.77E−04 0.04 1.77 1.04 MF GO:0003713~transcription coactivator activity 21 2.25 1.09E−02 0.20 1.83 15.59 MF GO:0008134~transcription factor binding 40 4.29 1.71E−02 0.26 1.45 23.40 MF GO:0003712~transcription cofactor activity 29 3.11 3.34E−02 0.38 1.49 40.88 Annotation Cluster 21 Enrichment Score: 2.01 MF GO:0050431~transforming growth factor 5 0.54 1.32E−03 0.05 9.33 2.02 beta binding MF GO:0019838~growth factor binding 13 1.39 1.03E−02 0.20 2.31 14.73 MF GO:0019955~cytokine binding 11 1.18 6.67E−02 0.53 1.88 65.61 Annotation Cluster 22 Enrichment Score: 2.00 BP GO:0002684~positive regulation of immune 30 3.22 2.42E−05 3.02E−03 2.37 0.04 system process BP GO:0002694~regulation of leukocyte activation 23 2.47 6.53E−05 5.81E−03 2.61 0.12 BP GO:0050865~regulation of cell activation 23 2.47 1.44E−04 9.73E−03 2.48 0.26 BP GO:0002696~positive regulation of leukocyte 16 1.71 4.55E−04 0.02 2.84 0.82 activation BP GO:0002819~regulation of adaptive immune 11 1.18 6.37E−04 0.03 3.70 1.15 response BP GO:0050867~positive regulation of cell 16 1.71 7.46E−04 0.03 2.72 1.34 activation BP GO:0050863~regulation of T cell activation 16 1.71 1.29E−03 0.04 2.58 2.31 BP GO:0051251~positive regulation of lymphocyte 14 1.50 1.78E−03 0.06 2.72 3.16 activation BP GO:0046635~positive regulation of alpha-beta 7 0.75 2.01E−03 0.06 5.07 3.57 T cell activation BP GO:0045621~positive regulation of lymphocyte 8 0.86 2.09E−03 0.06 4.31 3.71 differentiation BP GO:0050870~positive regulation of T cell 12 1.29 2.11E−03 0.06 2.97 3.75 activation BP GO:0051249~regulation of lymphocyte 18 1.93 2.16E−03 0.06 2.29 3.83 activation BP GO:0002822~regulation of adaptive immune 10 1.07 2.23E−03 0.07 3.43 3.95 response based on somatic recombination of immune receptors built from immunoglobulin superfamily domains BP GO:0046638~positive regulation of alpha-beta 6 0.64 3.29E−03 0.09 5.65 5.78 T cell differentiation BP GO:0045580~regulation of T cell differentiation 9 0.96 5.04E−03 0.12 3.32 8.74 BP GO:0045619~regulation of lymphocyte 10 1.07 5.69E−03 0.13 2.99 9.81 differentiation BP GO:0045582~positive regulation of T cell 7 0.75 6.03E−03 0.13 4.12 10.36 differentiation BP GO:0046637~regulation of alpha-beta T cell 6 0.64 9.04E−03 0.17 4.52 15.15 differentiation BP GO:0046634~regulation of alpha-beta T cell 7 0.75 1.08E−02 0.19 3.66 17.88 activation BP GO:0033081~regulation of T cell differentiation 4 0.43 1.78E−02 0.26 6.85 27.69 in the thymus BP GO:0043372~positive regulation of 4 0.43 1.78E−02 0.26 6.85 27.69 CD4-positive, alpha beta T cell differentiation BP GO:0002824~positive regulation of adaptive 6 0.64 1.95E−02 0.28 3.77 29.99 immune response based on somatic recombination of immune receptors built from immunoglobulin superfamily domains BP GO:0002706~regulation of lymphocyte 8 0.86 2.31E−02 0.31 2.79 34.52 mediated immunity BP GO:0043370~regulation of CD4-positive, alpha 4 0.43 4.19E−02 0.43 5.02 53.86 beta T cell differentiation BP GO:0002683~negative regulation of immune 9 0.96 7.24E−02 0.56 2.04 74.31 system process BP GO:0048585~negative regulation of response to 10 1.07 8.30E−02 0.59 1.88 79.14 stimulus BP GO:0050871~positive regulation of B cell 5 0.54 9.50E−02 0.63 2.85 83.58 activation BP GO:0002823~negative regulation of adaptive 3 0.32 1.12E−01 0.67 5.14 88.43 immune response based on somatic recombination of immune receptors built from immunoglobulin superfamily domains BP GO:0002820~negative regulation of adaptive 3 0.32 1.12E−01 0.67 5.14 88.43 immune response BP GO:0050777~negative regulation of immune 4 0.43 1.44E−01 0.74 3.01 94.01 response BP GO:0045577~regulation of B cell differentiation 3 0.32 2.07E−01 0.82 3.53 98.49 BP GO:0050670~regulation of lymphocyte 7 0.75 2.77E−01 0.88 1.59 99.71 proliferation BP GO:0050864~regulation of B cell activation 5 0.54 2.85E−01 0.89 1.85 99.77 BP GO:0070663~regulation of leukocyte 7 0.75 2.86E−01 0.89 1.57 99.77 proliferation BP GO:0032944~regulation of mononuclear cell 7 0.75 2.86E−01 0.89 1.57 99.77 proliferation BP GO:0030888~regulation of B cell proliferation 3 0.32 4.41E−01 0.96 2.02 100.00 Annotation Cluster 23 Enrichment Score: 1.96 MF GO:0051020~GTPase binding 14 1.50 5.41E−03 0.13 2.40 8.04 MF GO:0017016~Ras GTPase binding 12 1.29 9.14E−03 0.19 2.46 13.23 MF GO:0017048~Rho GTPase binding 7 0.75 1.47E−02 0.24 3.44 20.45 MF GO:0031267~small GTPase binding 12 1.29 1.90E−02 0.27 2.22 25.71 Annotation Cluster 24 Enrichment Score: 1.85 BP GO:0006730~one-carbon metabolic process 14 1.50 6.27E−03 0.14 2.36 10.76 BP GO:0043414~biopolymer methylation 10 1.07 1.03E−02 0.18 2.73 17.07 BP GO:0006479~protein amino acid methylation 7 0.75 1.59E−02 0.24 3.38 25.13 BP GO:0008213~protein amino acid alkylation 7 0.75 1.59E−02 0.24 3.38 25.13 BP GO:0032259~methylation 10 1.07 1.87E−02 0.27 2.48 28.92 BP GO:0016571~histone methylation 5 0.54 2.67E−02 0.34 4.28 38.71 Annotation Cluster 25 Enrichment Score: 1.84 BP GO:0010605~negative regulation of 60 6.43 8.43E−04 0.03 1.54 1.51 macromolecule metabolic process BP GO:0010629~negative regulation of gene 41 4.39 6.89E−03 0.14 1.53 11.75 expression BP GO:0016481~negative regulation of 38 4.07 7.21E−03 0.15 1.56 12.27 transcription BP GO:0010558~negative regulation of 43 4.61 9.92E−03 0.18 1.48 16.50 macromolecule biosynthetic process BP GO:0051253~negative regulation of RNA 31 3.32 1.03E−02 0.18 1.61 17.15 metabolic process BP GO:0009890~negative regulation of 44 4.72 1.32E−02 0.22 1.45 21.42 biosynthetic process BP GO:0045892~negative regulation of 30 3.22 1.41E−02 0.22 1.59 22.68 transcription, DNA-dependent BP GO:0051172~negative regulation of nitrogen 40 4.29 1.77E−02 0.26 1.45 27.59 compound metabolic process BP GO:0045934~negative regulation of 39 4.18 2.23E−02 0.30 1.44 33.48 nucleobase, nucleoside, nucleotide and nucleic acid metabolic process BP GO:0031327-negative regulation of cellular 42 4.50 2.26E−02 0.30 1.41 33.87 biosynthetic process MF GO:0016564~transcription repressor activity 25 2.68 5.35E−02 0.48 1.48 57.28 BP GO:0000122~negative regulation of 18 1.93 2.44E−01 0.86 1.27 99.37 transcription from RNA polymerase II promoter Annotation Cluster 26 Enrichment Score: 1.79 BP GO:0046907~intracellular transport 61 6.54 2.43E−05 2.91E−03 1.75 0.04 BP GO:0045184~establishment of protein 57 6.11 9.44E−03 0.18 1.40 15.77 localization BP GO:0015031~protein transport 56 6.00 1.16E−02 0.20 1.38 19.05 BP GO:0008104~protein localization 63 6.75 1.32E−02 0.22 1.35 21.32 BP GO:0006886~intracellular protein transport 25 2.68 1.91E−01 0.80 1.26 97.82 BP GO:0034613~cellular protein localization 27 2.89 1.99E−01 0.81 1.24 98.19 BP GO:0070727~cellular macromolecule 27 2.89 2.10E−01 0.83 1.23 98.59 localization Annotation Cluster 27 Enrichment Score: 1.75 BP GO:0010033~response to organic substance 61 6.54 3.21E−04 0.02 1.59 0.58 BP GO:0009725~response to hormone stimulus 32 3.43 6.98E−03 0.14 1.64 11.90 BP GO:0032870~cellular response to hormone 14 1.50 2.41E−02 0.32 1.98 35.71 stimulus BP GO:0009719~response to endogenous stimulus 32 3.43 2.53E−02 0.32 1.49 37.09 BP GO:0043434~response to peptide hormone 15 1.61 3.42E−02 0.39 1.84 46.67 stimulus BP GO:0032868~response to insulin stimulus 10 1.07 8.30E−02 0.59 1.88 79.14 BP GO:0032869~cellular response to insulin 7 0.75 1.51E−01 0.75 1.94 94.78 stimulus Annotation Cluster 28 Enrichment Score: 1.73 BP GO:0042108~positive regulation of cytokine 9 0.96 3.43E−03 0.09 3.53 6.03 biosynthetic process BP GO:0042035~regulation of cytokine 11 1.18 5.47E−03 0.13 2.80 9.44 biosynthetic process BP GO:0032677~regulation of interleukin-8 5 0.54 6.68E−03 0.14 6.28 11.42 production BP GO:0045414~regulation of interleukin-8 4 0.43 9.79E−03 0.18 8.37 16.30 biosynthetic process BP GO:0045416~positive regulation of 3 0.32 4.93E−02 0.47 8.07 59.94 interleukin-8 biosynthetic process BP GO:0007249~I-kappaB kinase/NF-kappaB 4 0.43 6.56E−01 0.99 1.20 100.00 cascade Annotation Cluster 29 Enrichment Score: 1.66 BP GO:0007044~cell-substrate junction assembly 6 0.64 6.25E−03 0.14 4.92 10.72 BP GO:0034329~cell junction assembly 7 0.75 2.00E−02 0.28 3.22 30.63 BP GO:0034330~cell junction organization 7 0.75 8.01E−02 0.58 2.31 77.91 Annotation Cluster 30 Enrichment Score: 1.64 BP GO:0045669~positive regulation of osteoblast 6 0.64 9.04E−03 0.17 4.52 15.15 differentiation BP GO:0045667~regulation of osteoblast 7 0.75 2.48E−02 0.32 3.07 36.55 differentiation BP GO:0030278~regulation of ossification 9 0.96 5.39E−02 0.49 2.17 63.30 Annotation Cluster 31 Enrichment Score: 1.61 BP GO:0048524~positive regulation of viral 4 0.43 1.34E−02 0.22 7.54 21.72 reproduction BP GO:0050792~regulation of viral reproduction 5 0.54 2.28E−02 0.30 4.49 34.08 BP GO:0046782~regulation of viral transcription 3 0.32 4.93E−02 0.47 8.07 59.94 Annotation Cluster 32 Enrichment Score: 1.56 BP GO:0007044~cell-substrate junction assembly 6 0.64 6.25E−03 0.14 4.92 10.72 BP GO:0007160~cell-matrix adhesion 10 1.07 4.58E−02 0.46 2.12 57.18 BP GO:0031589~cell-substrate adhesion 10 1.07 7.52E−02 0.57 1.92 75.68 Annotation Cluster 33 Enrichment Score: 1.55 BP GO:0002819~regulation of adaptive immune 11 1.18 6.37E−04 0.03 3.70 1.15 response BP GO:0002822~regulation of adaptive immune 10 1.07 2.23E−03 0.07 3.43 3.95 response based on somatic recombination of immune receptors built from immunoglobulin superfamily domains BP GO:0002697~regulation of immune effector 14 1.50 2.56E−03 0.07 2.61 4.53 process BP GO:0050778~positive regulation of immune 17 1.82 4.29E−03 0.11 2.21 7.48 response BP GO:0002703~regulation of leukocyte mediated 10 1.07 4.58E−03 0.11 3.09 7.97 immunity BP GO:0002821~positive regulation of adaptive 7 0.75 5.12E−03 0.12 4.25 8.87 immune response BP GO:0002699~positive regulation of immune 8 0.86 7.88E−03 0.16 3.43 13.33 effector process BP GO:0001910~regulation of leukocyte mediated 6 0.64 9.04E−03 0.17 4.52 15.15 cytotoxicity BP GO:0031349~positive regulation of defense 10 1.07 1.46E−02 0.23 2.58 23.42 response BP GO:0031341~regulation of cell killing 6 0.64 1.47E−02 0.23 4.04 23.47 BP GO:0002824~positive regulation of adaptive 6 0.64 1.95E−02 0.28 3.77 29.99 immune response based on somatic recombination of immune receptors built from immunoglobulin superfamily domains BP GO:0001912~positive regulation of leukocyte 5 0.54 2.28E−02 0.30 4.49 34.08 mediated cytotoxicity BP GO:0002706~regulation of lymphocyte 8 0.86 2.31E−02 0.31 2.79 34.52 mediated immunity BP GO:0002705~positive regulation of leukocyte 6 0.64 3.21E−02 0.38 3.32 44.54 mediated immunity BP GO:0002708~positive regulation of lymphocyte 6 0.64 3.21E−02 0.38 3.32 44.54 mediated immunity BP GO:0045089~positive regulation of innate 7 0.75 3.34E−02 0.38 2.87 45.94 immune response BP GO:0031343~positive regulation of cell killing 5 0.54 3.57E−02 0.39 3.93 48.18 BP GO:0045088~regulation of innate immune 7 0.75 6.49E−02 0.53 2.44 70.31 response BP GO:0001914~regulation of T cell mediated 3 0.32 7.88E−02 0.58 6.28 77.36 cytotoxicity BP GO:0002891~positive regulation of 3 0.32 1.12E−01 0.67 5.14 88.43 immunoglobulin mediated immune response BP GO:0002714~positive regulation of B cell 3 0.32 1.12E−01 0.67 5.14 88.43 mediated immunity BP GO:0002889~regulation of immunoglobulin 4 0.43 1.32E−01 0.71 3.14 92.23 mediated immune response BP GO:0002712~regulation of B cell mediated 4 0.43 1.32E−01 0.71 3.14 92.23 immunity BP GO:0045954~positive regulation of natural 3 0.32 2.07E−01 0.82 3.53 98.49 killer cell mediated cytotoxicity BP GO:0002717~positive regulation of natural 3 0.32 2.07E−01 0.82 3.53 98.49 killer cell mediated immunity BP GO:0042269~regulation of natural killer cell 3 0.32 2.27E−01 0.84 3.32 99.05 mediated cytotoxicity BP GO:0002715~regulation of natural killer cell 3 0.32 2.27E−01 0.84 3.32 99.05 mediated immunity BP GO:0002709~regulation of T cell mediated 3 0.32 3.07E−01 0.90 2.69 99.87 immunity Annotation Cluster 34 Enrichment Score: 1.55 BP GO:0043405~regulation of MAP kinase activity 18 1.93 1.27E−03 0.04 2.41 2.27 BP GO:0043406~positive regulation of MAP kinase 14 1.50 2.80E−03 0.08 2.59 4.94 activity BP GO:0043506~regulation of JUN kinase activity 7 0.75 1.24E−02 0.21 3.56 20.15 BP GO:0043507~positive regulation of JUN kinase 6 0.64 2.53E−02 0.33 3.53 37.09 activity BP GO:0043408~regulation of MAPKKK cascade 12 1.29 2.96E−02 0.36 2.07 41.87 BP GO:0080135~regulation of cellular response 11 1.18 4.62E−02 0.46 2.01 57.51 to stress BP GO:0046328~regulation of JNK cascade 8 0.86 5.56E−02 0.49 2.32 64.44 BP GO:0070302~regulation of stress-activated 8 0.86 7.21E−02 0.56 2.18 74.16 protein kinase signaling pathway BP GO:0007254~JNK cascade 7 0.75 9.12E−02 0.61 2.24 82.27 BP GO:0031098~stress-activated protein kinase 7 0.75 1.16E−01 0.68 2.09 89.20 signaling pathway BP GO:0007257~activation of JUN kinase activity 4 0.43 1.57E−01 0.76 2.90 95.43 Annotation Cluster 35 Enrichment Score: 1.54 BP GO:0051272~positive regulation of cell motion 13 1.39 5.55E−03 0.13 2.50 9.57 BP GO:0030335~positive regulation of cell 11 1.18 1.91E−02 0.27 2.33 29.46 migration BP GO:0051270~regulation of cell motion 18 1.93 2.76E−02 0.35 1.76 39.75 BP GO:0040017~positive regulation of locomotion 11 1.18 3.46E−02 0.39 2.11 47.10 BP GO:0030334~regulation of cell migration 15 1.61 6.51E−02 0.53 1.67 70.40 BP GO:0040012~regulation of locomotion 16 1.71 8.57E−02 0.60 1.57 80.20 Annotation Cluster 36 Enrichment Score: 1.47 BP GO:0030217~T cell differentiation 12 1.29 5.58E−04 0.02 3.48 1.01 BP GO:0046632~alpha-beta T cell differentiation 4 0.43 3.48E−02 0.39 5.38 47.34 BP GO:0046631~alpha-beta T cell activation 4 0.43 6.68E−02 0.54 4.19 71.37 BP GO:0000904~cell morphoProbe-setis involved 7 0.75 9.91E−01 1.00 0.54 100.00 in differentiation Annotation Cluster 37 Enrichment Score: 1.42 BP GO:0006952~defense response 50 5.36 2.72E−03 0.08 1.53 4.82 BP GO:0009611~response to wounding 36 3.86 1.04E−01 0.65 1.28 86.34 BP GO:0006954~inflammatory response 22 2.36 2.00E−01 0.81 1.28 98.24 Annotation Cluster 38 Enrichment Score: 1.41 BP GO:0007229~integrin-mediated signaling 9 0.96 3.12E−02 0.37 2.42 43.64 pathway MF GO:0005178~integrin binding 8 0.86 3.73E−02 0.40 2.53 44.39 BP GO:0033627~cell adhesion mediated by integrin 3 0.32 4.93E−02 0.47 8.07 59.94 Annotation Cluster 39 Enrichment Score: 1.40 BP GO:0050778~positive regulation of immune 17 1.82 4.29E−03 0.11 2.21 7.48 response BP GO:0002699~positive regulation of immune 8 0.86 7.88E−03 0.16 3.43 13.33 effector process BP GO:0031349~positive regulation of defense 10 1.07 1.46E−02 0.23 2.58 23.42 response BP GO:0002757~immune response-activating 8 0.86 1.91E−02 0.27 2.90 29.48 signal transduction BP GO:0002764~immune response-regulating 8 0.86 2.77E−02 0.35 2.69 39.82 signal transduction BP GO:0050852~T cell receptor signaling pathway 5 0.54 3.10E−02 0.37 4.10 43.43 BP GO:0045089~positive regulation of innate 7 0.75 3.34E−02 0.38 2.87 45.94 immune response BP GO:0002429~immune response-activating 6 0.64 5.36E−02 0.49 2.90 63.06 cell surface receptor signaling pathway BP GO:0045088~regulation of innate immune 7 0.75 6.49E−02 0.53 2.44 70.31 response BP GO:0002768~immune response-regulating cell 6 0.64 6.97E−02 0.55 2.69 72.92 surface receptor signaling pathway BP GO:0002758~innate immune response-activating 4 0.43 7.63E−02 0.57 3.97 76.22 signal transduction BP GO:0002218~activation of innate immune 4 0.43 7.63E−02 0.57 3.97 76.22 response BP GO:0050851~antigen receptor-mediated 5 0.54 9.50E−02 0.63 2.85 83.58 signaling pathway BP GO:0002253~activation of immune response 9 0.96 1.25E−01 0.70 1.80 91.07 BP GO:0002221~pattern recognition 3 0.32 2.27E−01 0.84 3.32 99.05 receptor signaling pathway Annotation Cluster 40 Enrichment Score: 1.39 BP GO:0000302~response to reactive oxygen 11 1.18 6.02E−03 0.13 2.76 10.34 species BP GO:0042542~response to hydrogen peroxide 9 0.96 8.92E−03 0.17 3.03 14.97 BP GO:0010035~response to inorganic substance 18 1.93 4.51E−02 0.45 1.65 56.60 BP GO:0006979~response to oxidative stress 14 1.50 9.58E−02 0.63 1.61 83.82 BP GO:0006800~oxygen and reactive oxygen 5 0.54 4.78E−01 0.97 1.41 100.00 species metabolic process Annotation Cluster 41 Enrichment Score: 1.35 BP GO:0009749~response to glucose stimulus 7 0.75 3.04E−02 0.36 2.93 42.77 BP GO:0009746~response to hexose stimulus 7 0.75 3.67E−02 0.40 2.81 49.13 BP GO:0034284~response to monosaccharide 7 0.75 3.67E−02 0.40 2.81 49.13 stimulus BP GO:0009743~response to carbohydrate stimulus 7 0.75 9.71E−02 0.63 2.20 84.22 Annotation Cluster 42 Enrichment Score: 1.34 MF GO:0016702~oxidoreductase activity, acting 9 0.96 2.40E−02 0.31 2.54 31.31 on single donors with incorporation of molecular oxygen, incorporation of two atoms of oxygen MF GO:0016701~oxidoreductase activity, acting on 9 0.96 2.60E−02 0.32 2.51 33.48 single donors with incorporation of molecular oxygen MF GO:0005506~iron ion binding 22 2.36 1.53E−01 0.73 1.33 92.29 Annotation Cluster 43 Enrichment Score: 1.27 BP GO:0007049~cell cycle 57 6.11 1.08E−02 0.19 1.38 17.84 BP GO:0000278~mitotic cell cycle 31 3.32 1.35E−02 0.22 1.58 21.81 BP GO:0022402~cell cycle process 42 4.50 2.52E−02 0.33 1.40 36.92 BP GO:0000082~G1/S transition of mitotic cell cycle 8 0.86 2.77E−02 0.35 2.69 39.82 BP GO:0022403~cell cycle phase 32 3.43 3.30E−02 0.38 1.46 45.46 BP GO:0051329~interphase of mitotic cell cycle 11 1.18 4.62E−02 0.46 2.01 57.51 BP GO:0000087~M phase of mitotic cell cycle 19 2.04 5.17E−02 0.48 1.60 61.72 BP GO:0051325~interphase 11 1.18 5.43E−02 0.49 1.96 63.58 BP GO:0007067~mitosis 18 1.93 7.65E−02 0.57 1.54 76.31 BP GO:0000280~nuclear division 18 1.93 7.65E−02 0.57 1.54 76.31 BP GO:0048285~organelle fission 18 1.93 1.01E−01 0.64 1.48 85.44 BP GO:0000279~M phase 21 2.25 2.92E−01 0.89 1.20 99.81 BP GO:0051301~cell division 18 1.93 3.93E−01 0.95 1.15 99.99 Annotation Cluster 44 Enrichment Score: 1.27 BP GO:0002252~immune effector process 19 2.04 2.48E−04 0.01 2.67 0.45 BP GO:0002443~leukocyte mediated immunity 11 1.18 1.53E−02 0.23 2.41 24.36 BP GO:0002467~germinal center formation 3 0.32 1.57E−02 0.24 14.13 24.85 BP GO:0002449~lymphocyte mediated immunity 8 0.86 7.66E−02 0.57 2.15 76.36 BP GO:0002460~adaptive immune response based 7 0.75 2.23E−01 0.84 1.71 98.96 on somatic recombination of immune receptors built from immunoglobulin superfamily domain BP GO:0002250~adaptive immune response 7 0.75 2.23E−01 0.84 1.71 98.96 BP GO:0016064~immunoglobulin mediated 4 0.43 5.51E−01 0.98 1.40 100.00 immune response BP GO:0019724~B cell mediated immunity 4 0.43 5.76E−01 0.99 1.35 100.00 Annotation Cluster 45 Enrichment Score: 1.22 BP GO:0010627~regulation of protein kinase 24 2.57 6.78E−03 0.14 1.82 11.58 cascade BP GO:0009967~positive regulation of signal 23 2.47 6.65E−02 0.53 1.47 71.19 transduction BP GO:0010647~positive regulation of cell 24 2.57 1.06E−01 0.65 1.37 86.74 communication BP GO:0010740~positive regulation of protein 12 1.29 2.72E−01 0.88 1.35 99.68 kinase cascade Annotation Cluster 46 Enrichment Score: 1.21 BP GO:0051651~maintenance of location in cell 7 0.75 4.01E−02 0.42 2.75 52.31 BP GO:0051235~maintenance of location 8 0.86 5.18E−02 0.48 2.36 61.81 BP GO:0032507~maintenance of protein location 6 0.64 6.40E−02 0.53 2.76 69.79 in cell BP GO:0045185~maintenance of protein location 6 0.64 1.09E−01 0.66 2.36 87.58 Annotation Cluster 47 Enrichment Score: 1.21 BP GO:0033619~membrane protein proteolysis 5 0.54 1.92E−02 0.27 4.71 29.61 BP GO:0006509~membrane protein ectodomain 4 0.43 4.19E−02 0.43 5.02 53.86 proteolysis BP GO:0007219~Notch signaling pathway 5 0.54 2.97E−01 0.90 1.81 99.83 Annotation Cluster 48 Enrichment Score: 1.20 BP GO:0001906~cell killing 5 0.54 3.57E−02 0.39 3.93 48.18 BP GO:0042267~natural killer cell mediated 3 0.32 6.35E−02 0.53 7.07 69.47 cytotoxicity BP GO:0002228~natural killer cell mediated 3 0.32 6.35E−02 0.53 7.07 69.47 immunity BP GO:0002449~lymphocyte mediated immunity 8 0.86 7.66E−02 0.57 2.15 76.36 BP GO:0001909~leukocyte mediated cytotoxicity 3 0.32 9.52E−02 0.63 5.65 83.62 Annotation Cluster 49 Enrichment Score: 1.19 BP GO:0010332~response to gamma radiation 6 0.64 6.25E−03 0.14 4.92 10.72 BP GO:0010212~response to ionizing radiation 8 0.86 3.85E−02 0.41 2.51 50.87 BP GO:0009314~response to radiation 15 1.61 1.76E−01 0.79 1.41 96.98 BP GO:0033077~T cell differentiation in the 3 0.32 4.23E−01 0.96 2.09 100.00 thymus Annotation Cluster 50 Enrichment Score: 1.17 BP GO:0001824~blastocyst development 9 0.96 1.67E−03 0.06 3.94 2.97 BP GO:0001829~trophectodermal cell differentiation 3 0.32 2.07E−01 0.82 3.53 98.49 BP GO:0001890~placenta development 6 0.64 2.11E−01 0.83 1.88 98.64 BP GO:0001825~blastocyst formation 3 0.32 2.87E−01 0.89 2.83 99.78 Top 50 clusters were included. The rest of the 50 clusters are decreasing in statistical significance and not shown. Abbreviations: BP, biological process. MF: molecular function. Adjusted P value is based on Benjammi method.

TABLE 15 KEGG pathway enrichment analysis using DAVID. The results are consistent with IPA pathway enrichment analysis. # of B-H adjusted Genes KEGG Pathway P value 21 T cell receptor signaling pathway 2.43E−04 18 Fc gamma R-mediated phagocytosis 1.20E−03 20 Neurotrophin signaling pathway 2.50E−03 15 Fc epsilon RI signaling pathway 3.26E−03 20 Natural killer cell mediated cytotoxicity 3.30E−03 26 Focal adhesion 3.66E−03 14 B cell receptor signaling pathway 4.79E−03 26 Regulation of actin cytoskeleton 6.65E−03 14 Small cell lung cancer 0.01 13 Chronic myeloid leukemia 0.01 20 Jak-STAT signaling pathway 0.01 33 Pathways in cancer 0.01 18 Insulin signaling pathway 0.02 22 Chemokine signaling pathway 0.02 28 MAPK signaling pathway 0.02 16 Leukocyte transendothelial migration 0.02 13 Hematopoietic cell lineage 0.02 12 VEGF signaling pathway 0.02 10 Non-small cell lung cancer 0.02 10 Pathogenic Escherichia coli infection 0.03

Example 2

TABLE 6 Gene panel Gene Name Gene Symbol Thrombospodin 1 THBS1 Rho guanine nucleotide exchange ARHGEF7 factor (GEF 7) MyoD family inhibitor domain MDFIC containing Cyclin D2 CCND2 Oxysterol binding protein-like 8 OSBPL8 DDB1 and CUL4 associated factor 7 DCAF7 Transmembrane protein 50B TMEM50B Golgin A8 family, member B GOLGA8A/GOLGA8B SWI/SNF related, matrix associated, SMARCA4 actin dependent regulator of chromatin subfamily a, member 4 Wolf-Hirschhorn syndrome WHSC1L1 candidate 1-like 1 Unnamed gene associated with the NA 1556747_a_at probe Unnamed gene associated with the NA 1562957_at probe

1556747_a_at identifies a novel long non-coding RNA gene “LOC101928343”, NCBI gene id is 101928343, and Ensembl ID is ENSG000002612227, human gene symbol is CTD-2006K23.1.

1562957_at identifies a long non-coding RNA gene “LINC00869”, NCBI gene ID is 57234, and Ensembl ID is ENSG00000226067, human gene symbol is LINC00869.

As described herein, a multivariate logistic regression model was developed for calculating the probability that a patient develops infections, e.g., multiple infections. This specific panel of genes, or the subsets thereof described herein, have never previously been described to have the ability to predict the outcome of multiple infections. Moreover, the prediction of multiple infections as an outcome using logistic regression models has never previously been described. The use of the specific panel(s) described herein, optionally combined with the use of logistic regression models, successfully predict the outcome of multiple infections. Given the expression value of each of the 12 genes (e.g. in an adult patient) or 5 gene panel (e.g., in a pediatric patient), in its entirety, or as a subset, the algorithm is able to predict the probability of multiple infections, e.g., using Glue Grant patients to build the predictive models. Information on the Total Body Surface Area (TBSA) burns, age and inhalation status (yes or no) can also be used in conjunction with the gene panel to improve prediction.

In this Example and some embodiments of the various aspect described herein, the expression values are numerical values of each of the genes, or a subset, derived from for example, microarray probe set expression level value, or by qPCR.

An example of the implementation of the algorithm is as such. Using the R software for this example and using microarray expression data of the entire 12 gene panel, with age, TBSA and inhalation status, the following code is run to obtain the coefficient of each of the covariate for the outcome of multiple infections in a given population, which in this case used the data from the GLUE grant.

mylogit<-glm(Outcome˜AGE+TBSA+Inhal_inj+X1556747_a_at+X1562957_at+X200951_s_at+X201108_s_at+X201109_s_at+X201110_s_at+X208797_s_at+X217599_s_at+X217656_at_+X221248_s_at+X222907_x_at+X224730_at+X228986_at+X235412_at, data=covariates, family=“binomial”) Age, TBSA and inhalation injury status, and the measured gene expression values of the 12 genes of each patient to be analyzed/predicted (“new data”) can then be entered into the following code implemented in the R software to predict the outcome of each patient: predicted<-predict.glm(mylogit, newdata=patient, type=“response”, se. fit=TRUE) patient is an R data frame containing age, TBSA, inhalation injury status, and the expression values of each of the 12 genes, in its entirety or as a subset, but always consistent with which covariates were used in the first formula.

The probability for multiple infection is stored in predicted$fit, and the 95% concidence interval is then calculated from the standard error stored in predicted$se.fit, by the formula predicted probability minus 1.96*standard error for the lower bound and predicted probability plus 1.96*standard error for the upper bound.

TABLE 7 Example coefficients of combined model, from microarray-derived data Coefficient Covariates Estimates Intercept −1.1912 TBSA 0.0423 Age 0.0652 Inhalation Injury (Yes) 3.5132 1556747_a_at −0.6652 (LOC101928343) 1562957_at (LINC00869) 0.803 200951_s_at (CCND2) 0.033 201108_s_at (THBS1) 0.8321 201109_s_at (THBS1) 0.8448 201110_s_at (THBS1) 0.0714 208797_s_at −0.731 (GOLGA8A/GOLGA8B) 217599_s_at (MDFIC) −0.146 217656_at (SMARCA4) −1.0108 221248_s_at (WHSC1L1) −1.2438 222907_x_at (TMEM50B) −0.167 224730_at (DCAF7) −1.4905 228986_at (OSBPL8) 0.1821 235412_at (ARHGEF7) 0.8709

Minimal Sets.

The set of marker genes of Table 8 can be used to permit prosnosis for, and/or treatment plans to patients as described herein. In some embodiments, the set of genes of Table 8 can permit prosnosis for, and/or treatment plans to patients 16 years of age or older.

TABLE 8 Minimal set, e.g. for adult blood samples CCND2 cyclin D2 THBS1 thrombospondin 1 MDFIC MyoD family inhibitor domain containing SMARCA4 SWI/SNF related, matrix associated, actin dependent regulator of chromatin, subfamily a, member 4 WHSC1L1 Wolf-Hirschhorn syndrome candidate 1-like 1 TMEM50B transmembrane protein 50B DCAF7 DDB1 and CUL4 associated factor 7 OSBPL8 oxysterol binding protein-like 8

The set of marker genes of Table 9 can be permit prosnosis for, and/or treatment plans to patients as described herein. In some embodiments, the set of genes of Table 9 can permit prosnosis for, and/or treatment plans to patients of 15 years of age or younger.

TABLE 9 Minimal set, e.g. for pediatric blood samples. Fold change is in the hypersusceptible patients compared to those less vulnerable. Fold Minimal set for Pediatric Blood Samples Change NFKB2 nuclear factor of kappa light polypeptide 1.78 gene enhancer in B-cells 2 (p49/p100) MAX MYC associated factor X 1.67 PDLIM5 PDZ and LIM domain 5 −1.43 GATAD2B GATA zinc finger domain containing 2B −1.50 ZSCAN30 zinc finger and SCAN domain containing 30 −1.36

Additional Muscle Biomarkers:

Several ALDHs were also found to be associated with increase burn wound infections. In some embodiments, the level of one or more ALDHs of Table 10 can be used in the methods described herein to provide prognosis and/or treatment plans for a subject at risk of infection. In some embodiments, the level of ALDH is the level in the muscle of the subject.

TABLE 10 Muscle Expression of ALDHs Fold change in Fold change in burn patients burn patients who had 2 or who had 3 or Fold more burn wound more burn wound change in infections than infections than burn vs. burn patients burn patients Gene Probe healthy had no infection had no infection ALDH1A1 212224_at −2.55 −1.65 −1.64 ALDH1A2 207016_s_at — −1.98 −1.91 ALDH3B1 211004_s_at — 1.85 1.91 ALDH5A1 203608_at −1.87 −2.67 −3.17 ALDH6A1 221588_x_at −1.42 −1.76 −1.82 ALDH7A1 208950_s_at −2.25 — −1.56 —: fold change < 1.3 fold 

What is claimed herein is:
 1. A method comprising: (a) obtaining a leukocyte sample from a burn patient 16 years of age or older and suspected of being at risk of a Pseudomonas or Staphylococci infection or having a Pseudomonas or Staphylococci infection; (b) isolating RNA from the sample; (c) analyzing the isolated RNA using RT-PCR for gene expression levels of at least one gene selected from the group of: Thrombospondin 1 (THBS1); cyclin D2 (CCND2); MyoD family inhibitor domain containing (MDFIC); SWI/SNF related, matrix associated, actin dependent regulator of chromatin, subfamily a, member 4 (SMARCA4); nuclear receptor binding SET domain protein 3 (WHSC1L1); transmembrane protein 50B (TMEM50B); DDB1 and CUL4 associated factor 7 (DCAF7); and oxysterol binding protein like 8 (OSBPL8); (d) determining the values of total body surface area (TBSA) burns, age, and inhalation status of the burn patient; and (e) multiplying the TBSA value by 0.0423; multiplying the age value by 0.0652; multiplying the inhalation status value by 3.5132; and multiplying the expression level of each measured gene by a coefficient selected from the group of: 0.8321 for the expression level of Thrombospondin 1 (THBS1) analyzed using sequence comprising probe 201108; 0.8448 for the expression level of Thrombospondin 1 (THBS1) analyzed using the sequence comprising probe 201109, 0.0714 for the expression level of Thrombospondin 1 (THBS1) analyzed using the sequence comprising probe 201110; 0.033 for the expression level of cyclin D2 (CCND2); −0.146 for the expression level of MyoD family inhibitor domain containing (MDFIC); −1.0108 for the expression level of SWI/SNF related, matrix associated, actin dependent regulator of chromatin, subfamily a, member 4 (SMARCA4); −1.2438 for the expression level of nuclear receptor binding SET domain protein 3 (WHSC1L1); −0.167 for the expression level of transmembrane protein 50B (TMEM50B); −1.4905 for the expression level of DDB1 and CUL4 associated factor 7 (DCAF7); 0.1821 for the expression level of oxysterol binding protein like 8 (OSBPL8); and adding the resulting products to yield a risk value.
 2. The method of claim 1, wherein a risk value is greater than or about −1.1912 indicates the subject should be administered at least one treatment selected from the group consisting of: antibiotics; immunotherapy; and LPS removal.
 3. The method of claim 1, wherein the sample comprises blood or plasma. 